Healthcare Provider Details

I. General information

NPI: 1114067964
Provider Name (Legal Business Name): KRYSTAL LEE MORRIS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

941 BURR ST APT E
FORT BENNING GA
31905-8770
US

V. Phone/Fax

Practice location:
  • Phone: 435-696-5912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number017083
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberPT017083
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: