Healthcare Provider Details

I. General information

NPI: 1003046087
Provider Name (Legal Business Name): KRYSTAL ANN WELLS OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTAL ANN CHRISTENSEN OD

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 09/09/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 DODGE ST
OMAHA NE
68131-2709
US

IV. Provider business mailing address

4353 DODGE ST
OMAHA NE
68131-2709
US

V. Phone/Fax

Practice location:
  • Phone: 402-552-2020
  • Fax: 402-552-2367
Mailing address:
  • Phone: 402-552-2020
  • Fax: 402-552-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1342
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002462
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: