Provider Demographics
NPI:1790098267
Name:HAWORTH, KRYSTAL SHIRLEY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:SHIRLEY
Last Name:HAWORTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4944
Mailing Address - Country:US
Mailing Address - Phone:386-492-2958
Mailing Address - Fax:
Practice Address - Street 1:240 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-4944
Practice Address - Country:US
Practice Address - Phone:386-492-2958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59309225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist