Provider Demographics
NPI:1023983574
Name:VELASCO, KRYSTAL AMANDA (PMHNP)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:AMANDA
Last Name:VELASCO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1713 CASEROS DR
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-3305
Mailing Address - Country:US
Mailing Address - Phone:909-781-9524
Mailing Address - Fax:
Practice Address - Street 1:8300 UTICA AVE STE 259
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3852
Practice Address - Country:US
Practice Address - Phone:909-906-1505
Practice Address - Fax:909-906-1508
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95037330363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health