Provider Demographics
NPI:1992004329
Name:SAMUEL, KRISTAL
Entity Type:Individual
Prefix:MS
First Name:KRISTAL
Middle Name:
Last Name:SAMUEL
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 1:1321 MCMILLAN AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-1324
Mailing Address - Country:US
Mailing Address - Phone:251-867-3242
Mailing Address - Fax:251-867-7151
Practice Address - Street 1:1321 MCMILLAN AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1324
Practice Address - Country:US
Practice Address - Phone:251-867-3242
Practice Address - Fax:251-867-7151
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-057363164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse