Provider Demographics
NPI:1457850414
Name:RICHARDSON, KRYSTAL (FNP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:HADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 FOURTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:461 W. HURON SUITE 107
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341
Practice Address - Country:US
Practice Address - Phone:248-724-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704289683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily