Healthcare Provider Details

I. General information

NPI: 1427474311
Provider Name (Legal Business Name): KRYSTAL NEWKIRK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2014
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 LULA ST NW
LILBURN GA
30047-3850
US

IV. Provider business mailing address

1580 CARPENTER RD S
TIFTON GA
31793-7926
US

V. Phone/Fax

Practice location:
  • Phone: 678-697-6049
  • Fax:
Mailing address:
  • Phone: 229-854-3607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT005809
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: