Healthcare Provider Details

I. General information

NPI: 1811424708
Provider Name (Legal Business Name): KRYSTAL FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 07/21/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 REPUBLIC PKWY STE 101
MESQUITE TX
75150-6902
US

IV. Provider business mailing address

1675 REPUBLIC PKWY STE 100
MESQUITE TX
75150-6902
US

V. Phone/Fax

Practice location:
  • Phone: 972-576-7399
  • Fax: 972-476-0006
Mailing address:
  • Phone: 972-576-7399
  • Fax: 972-476-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEYNA OMENUKOR
Title or Position: CEO
Credential: NP
Phone: 972-576-7399