Healthcare Provider Details

I. General information

NPI: 1245837178
Provider Name (Legal Business Name): KRYSTAL KNIGHT LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S BROWN ST
SPRINGFIELD TN
37172-2920
US

IV. Provider business mailing address

724 DARROW DR
PLEASANT VIEW TN
37146-8073
US

V. Phone/Fax

Practice location:
  • Phone: 615-384-4504
  • Fax:
Mailing address:
  • Phone: 615-604-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number85768
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: