Provider Demographics
NPI:1336751767
Name:CARPENTER, KRYSTAL V
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:V
Last Name:CARPENTER
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 1:8416 COUNTY ROAD 279
Mailing Address - Street 2:
Mailing Address - City:RIO MEDINA
Mailing Address - State:TX
Mailing Address - Zip Code:78066-2521
Mailing Address - Country:US
Mailing Address - Phone:210-965-1611
Mailing Address - Fax:
Practice Address - Street 1:8416 COUNTY ROAD 279
Practice Address - Street 2:
Practice Address - City:RIO MEDINA
Practice Address - State:TX
Practice Address - Zip Code:78066-2521
Practice Address - Country:US
Practice Address - Phone:210-965-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX329514164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse