Healthcare Provider Details

I. General information

NPI: 1205730264
Provider Name (Legal Business Name): KRYSTAL MBAMALU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 S NEDDERMAN DRIVE PICKARD HALL BOX 19407
ARLINGTON TX
76019-0407
US

IV. Provider business mailing address

4030 CHAMPLAIN WAY
ROSHARON TX
77583-3961
US

V. Phone/Fax

Practice location:
  • Phone: 817-272-2776
  • Fax: 817-272-5006
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: