Provider Demographics
NPI:1205440898
Name:SITTHIVONG, KRYSTAL LYNN (CNP)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
Last Name:SITTHIVONG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2569
Practice Address - Country:US
Practice Address - Phone:228-867-4499
Practice Address - Fax:228-867-5027
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904763363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner