MEDICARE: MRS. KRYSTAL YOUNG LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant
2	164W00000X	Licensed Practical Nurse	20180184	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20180184	OTHER	LA	LPN
2	0000000	OTHER		PPO

General Provider Information

NPI Number	:	1366099939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRYSTAL YOUNG LPN

Provider Business Mailing Address
First Line	:	1304 BERTRAND DR STE D5
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-9104
Country	:	US
Telephone Number	:	337-446-1223
Fax Number	:	337-269-5964

Provider Business Practice Location Address
First Line	:	1304 BERTRAND DR STE D5
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-9104
Country	:	US
Telephone Number	:	337-446-1223
Fax Number	:	337-269-5964

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2019
Last Update Date	:	02/05/2020

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