Provider Demographics
NPI:1689915415
Name:DIAZ, KRYSTLE MARIE (APRN, FNP)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:APRN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 CLARK CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70611-3528
Mailing Address - Country:US
Mailing Address - Phone:337-802-5800
Mailing Address - Fax:
Practice Address - Street 1:217 SAM HOUSTON JONES PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-5644
Practice Address - Country:US
Practice Address - Phone:337-217-1000
Practice Address - Fax:337-217-1004
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07247363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily