Provider Demographics
NPI:1508478983
Name:WILLEY, KRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:WILLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 WATER VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920-3693
Mailing Address - Country:US
Mailing Address - Phone:630-465-6858
Mailing Address - Fax:
Practice Address - Street 1:11531 SUNDERLAND RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-8274
Practice Address - Country:US
Practice Address - Phone:618-964-5139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.129144164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse