Healthcare Provider Details

I. General information

NPI: 1952282428
Provider Name (Legal Business Name): KRYSTAL MARIE BLANTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SAN PABLO LN
EDGEWOOD NM
87015-6836
US

IV. Provider business mailing address

PO BOX 1207
EDGEWOOD NM
87015-1207
US

V. Phone/Fax

Practice location:
  • Phone: 505-785-1155
  • Fax:
Mailing address:
  • Phone: 505-785-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: