Healthcare Provider Details

I. General information

NPI: 1922825884
Provider Name (Legal Business Name): KRYSTAL MARIE ACTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 GROVE AVE
RICHMOND VA
23220-4308
US

IV. Provider business mailing address

38 HORSESHOE BND
BUMPASS VA
23024-2316
US

V. Phone/Fax

Practice location:
  • Phone: 804-254-9735
  • Fax:
Mailing address:
  • Phone: 804-347-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number0024185394
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: