Provider Demographics
NPI:1922477918
Name:PETERSON, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SOYBEAN DR
Mailing Address - Street 2:
Mailing Address - City:APPOMATTOX
Mailing Address - State:VA
Mailing Address - Zip Code:24522-4308
Mailing Address - Country:US
Mailing Address - Phone:434-258-7818
Mailing Address - Fax:434-664-2023
Practice Address - Street 1:311 SOYBEAN DR
Practice Address - Street 2:
Practice Address - City:APPOMATTOX
Practice Address - State:VA
Practice Address - Zip Code:24522-4308
Practice Address - Country:US
Practice Address - Phone:434-258-7818
Practice Address - Fax:434-664-2023
Is Sole Proprietor?:No
Enumeration Date:2015-09-19
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator