Provider Demographics
NPI:1629543350
Name:THOMAS, KRYSTA DIANE
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:DIANE
Last Name:THOMAS
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 1:4722 PARKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32955-6578
Mailing Address - Country:US
Mailing Address - Phone:228-265-4326
Mailing Address - Fax:
Practice Address - Street 1:4722 PARKSTONE DR
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32955-6578
Practice Address - Country:US
Practice Address - Phone:228-265-4326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00000000000000Medicaid