Healthcare Provider Details

I. General information

NPI: 1093656134
Provider Name (Legal Business Name): CRYSTAL DENISE KOONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 NIELSON RD
KINDER LA
70648-5300
US

IV. Provider business mailing address

141 NIELSON RD
KINDER LA
70648-5300
US

V. Phone/Fax

Practice location:
  • Phone: 337-603-7892
  • Fax:
Mailing address:
  • Phone: 337-603-7892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number007683671
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: