Healthcare Provider Details

I. General information

NPI: 1720161607
Provider Name (Legal Business Name): JACK PHIL KRYSTYN JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 CARAVAN LN
KINSEY AL
36303-7694
US

IV. Provider business mailing address

184 CARAVAN LN
KINSEY AL
36303-7694
US

V. Phone/Fax

Practice location:
  • Phone: 334-678-8268
  • Fax:
Mailing address:
  • Phone: 334-678-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1-03341
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: