Provider Demographics
NPI:1245965979
Name:NELSON, KRYSTAL
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:NELSON
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 1:11501 KUMQUAT ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-2332
Mailing Address - Country:US
Mailing Address - Phone:214-206-6478
Mailing Address - Fax:
Practice Address - Street 1:685 13TH AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1459
Practice Address - Country:US
Practice Address - Phone:214-206-6478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN528379235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist