Healthcare Provider Details

I. General information

NPI: 1770934820
Provider Name (Legal Business Name): KRYSTAL KIM SHENK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING STREET, NW
WASHINGTON DC
20010
US

IV. Provider business mailing address

5565 STERETT PLACE
COLUMBIA MD
21044
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-6781
  • Fax: 202-877-8118
Mailing address:
  • Phone: 877-772-6505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN55812
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: