Provider Demographics
NPI:1760124739
Name:ROLLE, KRYSTAL (LVN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:ROLLE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E HARRY BRIDGES BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-5825
Mailing Address - Country:US
Mailing Address - Phone:310-549-8383
Mailing Address - Fax:310-549-9304
Practice Address - Street 1:117 E HARRY BRIDGES BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-5825
Practice Address - Country:US
Practice Address - Phone:310-549-8383
Practice Address - Fax:310-549-9304
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA707780164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse