Healthcare Provider Details

I. General information

NPI: 1689761058
Provider Name (Legal Business Name): MS. KRYSTAL LEAH SYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 WINCHESTER RD SOUTHEAST MENTAL HEALTH CENTER
MEMPHIS TN
38118-9007
US

IV. Provider business mailing address

2579 DOUGLASS AVE
MEMPHIS TN
38114-2532
US

V. Phone/Fax

Practice location:
  • Phone: 901-369-1420
  • Fax: 901-369-1433
Mailing address:
  • Phone: 901-369-1480
  • Fax: 901-312-7572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number20642
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: