Provider Demographics
NPI:1205461761
Name:DILL, KRYSTAL WILLIDEAN
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:WILLIDEAN
Last Name:DILL
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 1:1628 COUNTY ROAD 1425
Mailing Address - Street 2:
Mailing Address - City:BOGATA
Mailing Address - State:TX
Mailing Address - Zip Code:75417-5639
Mailing Address - Country:US
Mailing Address - Phone:903-900-0536
Mailing Address - Fax:
Practice Address - Street 1:1628 COUNTY ROAD 1425
Practice Address - Street 2:
Practice Address - City:BOGATA
Practice Address - State:TX
Practice Address - Zip Code:75417-5639
Practice Address - Country:US
Practice Address - Phone:903-900-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346556164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse