Provider Demographics
NPI:1922627637
Name:LUGO, KRYSTAL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:LUGO
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 1:3940 SUMMER BREEZE CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-2840
Mailing Address - Country:US
Mailing Address - Phone:901-628-1073
Mailing Address - Fax:
Practice Address - Street 1:3940 SUMMER BREEZE CV
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-2840
Practice Address - Country:US
Practice Address - Phone:901-628-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program