Healthcare Provider Details

I. General information

NPI: 1659841591
Provider Name (Legal Business Name): KRYSTAL JOHNSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 TEASLEY LN
DENTON TX
76205-7946
US

IV. Provider business mailing address

4601 66TH ST STE D
LUBBOCK TX
79414-4875
US

V. Phone/Fax

Practice location:
  • Phone: 866-832-1708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2143097
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: