Healthcare Provider Details

I. General information

NPI: 1811479199
Provider Name (Legal Business Name): KRYSTLE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2018
Last Update Date: 09/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 DEADMOND FERRY RD
SPRINGFIELD OR
97477-9406
US

IV. Provider business mailing address

353 DEADMOND FERRY RD
SPRINGFIELD OR
97477-9406
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-7750
  • Fax:
Mailing address:
  • Phone: 541-222-7750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number200442030RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number200442030RN
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number200442030RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: