Provider Demographics
NPI:1821725961
Name:KOIVISTO, KRYSTAL LYNN (HIS)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
Last Name:KOIVISTO
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:LYNN
Other - Last Name:BETTRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HIS
Mailing Address - Street 1:1515 US HIGHWAY 1 STE 104
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-1612
Mailing Address - Country:US
Mailing Address - Phone:772-388-2343
Mailing Address - Fax:
Practice Address - Street 1:1515 US HIGHWAY 1 STE 104
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-1612
Practice Address - Country:US
Practice Address - Phone:772-388-2343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5660237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist