Provider Demographics
NPI:1801381645
Name:RICHARDSON, KRYSTEN LEEANN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTEN
Middle Name:LEEANN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MISS
Other - First Name:KRYSTEN
Other - Middle Name:LEEANN
Other - Last Name:CROSSLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:1751 VETERANS DR STE 300
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-4930
Mailing Address - Country:US
Mailing Address - Phone:256-718-3200
Mailing Address - Fax:256-246-3297
Practice Address - Street 1:1751 VETERANS DR STE 300
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-4930
Practice Address - Country:US
Practice Address - Phone:256-718-3200
Practice Address - Fax:256-246-3297
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3576363A00000X
AL1346363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL267297Medicaid
TNQ037209Medicaid