Healthcare Provider Details

I. General information

NPI: 1598580060
Provider Name (Legal Business Name): KRYSTAL CORDELL HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W BASELINE RD STE 9
GILBERT AZ
85233-1012
US

IV. Provider business mailing address

750 N COMMONS DR STE 200
AURORA IL
60504-8025
US

V. Phone/Fax

Practice location:
  • Phone: 480-633-1830
  • Fax:
Mailing address:
  • Phone: 630-303-5380
  • Fax: 630-303-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHADE15808
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: