Provider Demographics
NPI:1689332553
Name:ELDRETH, KRYSTAL (AP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:ELDRETH
Suffix:
Gender:F
Credentials:AP
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 904
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0904
Mailing Address - Country:US
Mailing Address - Phone:850-723-1730
Mailing Address - Fax:
Practice Address - Street 1:107 BAY BRIDGE DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7428
Practice Address - Country:US
Practice Address - Phone:850-723-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4298171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist