Provider Demographics
NPI:1649575960
Name:EDGAR, KRYSTAL KAY (CRNA)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:KAY
Last Name:EDGAR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:KAY
Other - Last Name:CARVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT.
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:NEMOURS CHILDRENS CLINIC, JACKSONVILLE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:904-396-1630
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9245587367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107670BMedicaid
FL0031396-00Medicaid
GA003107670AMedicaid
GA003107670AMedicaid
GA003107670BMedicaid