Provider Demographics
NPI:1659580702
Name:ALLEN, KRYSTAL SHERRI (DC)
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:SHERRI
Last Name:ALLEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 986
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95258-0986
Mailing Address - Country:US
Mailing Address - Phone:209-339-9036
Mailing Address - Fax:
Practice Address - Street 1:2000 W KETTLEMAN LN STE 104
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4334
Practice Address - Country:US
Practice Address - Phone:209-334-6947
Practice Address - Fax:209-334-6969
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 30023111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0300230Medicare UPIN
CADC0300230Medicare PIN