Healthcare Provider Details

I. General information

NPI: 1073185153
Provider Name (Legal Business Name): KRYSTAL ANNE FAIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 PAGE PLACE RD
STATESBORO GA
30458-9050
US

IV. Provider business mailing address

505 N CLARK ST
CLAXTON GA
30417-1516
US

V. Phone/Fax

Practice location:
  • Phone: 912-259-9619
  • Fax: 912-259-9618
Mailing address:
  • Phone: 912-531-0616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN213761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: