Provider Demographics
NPI:1639831860
Name:KOUDER, KRYSTAL LYNN (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
Last Name:KOUDER
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5843 TAHOE PL
Mailing Address - Street 2:
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-0676
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5843 TAHOE PL
Practice Address - Street 2:
Practice Address - City:CEDAR LAKE
Practice Address - State:IN
Practice Address - Zip Code:46303-0676
Practice Address - Country:US
Practice Address - Phone:843-743-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2022-03-22
Deactivation Date:2021-11-30
Deactivation Code:
Reactivation Date:2022-03-22
Provider Licenses
StateLicense IDTaxonomies
IN28156517A163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant