Healthcare Provider Details

I. General information

NPI: 1679183628
Provider Name (Legal Business Name): KRYSTA GOOLSBY HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3146 LITTLE RD
TRINITY FL
34655-1864
US

IV. Provider business mailing address

3146 LITTLE RD
TRINITY FL
34655-1864
US

V. Phone/Fax

Practice location:
  • Phone: 727-807-5694
  • Fax:
Mailing address:
  • Phone: 727-807-5694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5144
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: