Provider Demographics
NPI:1780364844
Name:TOLIVER, KRYSTAL CHIVON
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:CHIVON
Last Name:TOLIVER
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 1:4307 CARLIN AVE UNIT 19
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-5455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4307 CARLIN AVE UNIT 19
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-5455
Practice Address - Country:US
Practice Address - Phone:310-418-3496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95118352363LS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool