Provider Demographics
NPI:1902831464
Name:OVERLY, KRYSTAL S (ARNP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:S
Last Name:OVERLY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 S BLUE ANGEL PKWY
Mailing Address - Street 2:# 104
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-6045
Mailing Address - Country:US
Mailing Address - Phone:850-529-7932
Mailing Address - Fax:
Practice Address - Street 1:12385 SORRENTO RD STE A4
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-8656
Practice Address - Country:US
Practice Address - Phone:850-602-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3248772363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00233924OtherRR MEDICARE
FL307094800Medicaid
FLY075YZMedicare PIN
P00233924OtherRR MEDICARE