Provider Demographics
NPI:1508575184
Name:MANNING, KRYSTAL LYNN
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
Last Name:MANNING
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:LYNN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1620 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4547
Practice Address - Country:US
Practice Address - Phone:208-505-2950
Practice Address - Fax:208-505-2955
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146126106H00000X
ID2061075106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist