Provider Demographics
NPI:1609494913
Name:GARD, KRYSTLE
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:GARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15888 SW SUNDEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2694
Mailing Address - Country:US
Mailing Address - Phone:907-250-7569
Mailing Address - Fax:
Practice Address - Street 1:15888 SW SUNDEW DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-2694
Practice Address - Country:US
Practice Address - Phone:907-250-7569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty