Healthcare Provider Details

I. General information

NPI: 1225620032
Provider Name (Legal Business Name): THEODORE JOHN KRZYSIK MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 W DALLAS ST
CONROE TX
77301-2208
US

IV. Provider business mailing address

1150 W DALLAS ST
CONROE TX
77301-2208
US

V. Phone/Fax

Practice location:
  • Phone: 713-955-4510
  • Fax:
Mailing address:
  • Phone: 713-955-4510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704317818
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907853
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209034864
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704317818
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1123912
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: