Provider Demographics
NPI:1609207166
Name:HUMBLE, KHRYSTAL KAY (BA)
Entity Type:Individual
Prefix:
First Name:KHRYSTAL
Middle Name:KAY
Last Name:HUMBLE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E FRESNO AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2817
Mailing Address - Country:US
Mailing Address - Phone:580-767-9035
Mailing Address - Fax:580-762-1157
Practice Address - Street 1:508 E FRESNO AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2817
Practice Address - Country:US
Practice Address - Phone:580-767-9035
Practice Address - Fax:580-762-1157
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK157768174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator