Provider Demographics
NPI:1922760198
Name:ALLEN, KRYSTAL (RN,BSN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RN,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5695
Mailing Address - Country:US
Mailing Address - Phone:708-482-6848
Mailing Address - Fax:708-482-6569
Practice Address - Street 1:315 N LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5695
Practice Address - Country:US
Practice Address - Phone:708-482-6848
Practice Address - Fax:708-482-6569
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04148905163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse