Healthcare Provider Details

I. General information

NPI: 1750742219
Provider Name (Legal Business Name): KRYSTLE CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2016
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 FIFTH ST
JACKSON MI
49203-5827
US

IV. Provider business mailing address

716 FIFTH ST
JACKSON MI
49203-5827
US

V. Phone/Fax

Practice location:
  • Phone: 517-740-8000
  • Fax:
Mailing address:
  • Phone: 517-740-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703103892
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: