Provider Demographics
NPI:1922705276
Name:HUDNELL, KRYSTLE SUE
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:SUE
Last Name:HUDNELL
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 1:751 RANCHEROS DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-3041
Mailing Address - Country:US
Mailing Address - Phone:760-761-0515
Mailing Address - Fax:760-761-0464
Practice Address - Street 1:751 RANCHEROS DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-3041
Practice Address - Country:US
Practice Address - Phone:760-761-0515
Practice Address - Fax:760-761-0464
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1023146826OtherOTHER NON MEDICARE