Provider Demographics
NPI:1619215191
Name:PHILLIPS, KRYSTAL ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:ANN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KRYSTAL
Other - Middle Name:ANN
Other - Last Name:RUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:13720 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13720 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-2602
Practice Address - Country:US
Practice Address - Phone:314-896-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013001163111NR0400X, 111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NS0005XChiropractic ProvidersChiropractorSports Physician