Provider Demographics
NPI:1336573641
Name:MEDLEY, KRYSTAL M (APRN)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:M
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 TRIPLETT ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-3163
Mailing Address - Country:US
Mailing Address - Phone:270-688-4325
Mailing Address - Fax:270-687-4322
Practice Address - Street 1:1325 TRIPLETT ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3163
Practice Address - Country:US
Practice Address - Phone:270-688-4325
Practice Address - Fax:270-687-4322
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008181363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100261310Medicaid
IN201204360Medicaid
IN201204360Medicaid