Healthcare Provider Details

I. General information

NPI: 1982178083
Provider Name (Legal Business Name): KRYSTAL LATOYIA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2019
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

IV. Provider business mailing address

1709 MOON ST NE
ALBUQUERQUE NM
87112-3935
US

V. Phone/Fax

Practice location:
  • Phone: 505-271-0329
  • Fax: 505-271-4957
Mailing address:
  • Phone: 505-271-0329
  • Fax: 505-271-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: