Provider Demographics
NPI:1336783885
Name:HUBBARD, KRYSTAL ATHENA
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ATHENA
Last Name:HUBBARD
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 1:19300 WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1531
Mailing Address - Country:US
Mailing Address - Phone:313-715-1554
Mailing Address - Fax:
Practice Address - Street 1:1121 E MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2857
Practice Address - Country:US
Practice Address - Phone:313-365-3100
Practice Address - Fax:313-365-3101
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist