Healthcare Provider Details

I. General information

NPI: 1497124945
Provider Name (Legal Business Name): KRYSTAL BAUMAN CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6008 FOX HAVEN CT
WOODBRIDGE VA
22193-4008
US

IV. Provider business mailing address

6008 FOX HAVEN CT
WOODBRIDGE VA
22193-4008
US

V. Phone/Fax

Practice location:
  • Phone: 757-254-7161
  • Fax:
Mailing address:
  • Phone: 757-254-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number237218
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number041.367227
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: