Healthcare Provider Details

I. General information

NPI: 1366738015
Provider Name (Legal Business Name): KRYSTLE NICOLE DE LA ROSA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10419 BULWARK PEAK
CONVERSE TX
78109-1988
US

IV. Provider business mailing address

10419 BULWARK PEAK
CONVERSE TX
78109-1988
US

V. Phone/Fax

Practice location:
  • Phone: 617-416-8139
  • Fax:
Mailing address:
  • Phone: 617-416-8139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number793780
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: