Provider Demographics
NPI:1851961445
Name:NELSON, KRYSTAL DAWN (OD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:DAWN
Last Name:NELSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19125 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:BATESLAND
Mailing Address - State:SD
Mailing Address - Zip Code:57716-3072
Mailing Address - Country:US
Mailing Address - Phone:308-360-3633
Mailing Address - Fax:
Practice Address - Street 1:516 EAST NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12351314-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program