Healthcare Provider Details

I. General information

NPI: 1417692989
Provider Name (Legal Business Name): KRYSTAL HAMPTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 03/01/2026
Certification Date: 03/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3829 MARY AVE
BALTIMORE MD
21206-2419
US

IV. Provider business mailing address

3829 MARY AVE
BALTIMORE MD
21206-2419
US

V. Phone/Fax

Practice location:
  • Phone: 443-469-0291
  • Fax:
Mailing address:
  • Phone: 443-469-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: