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General NPI Number Information
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NPI Number | 1548668601
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Entity Type | Individual
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Provider Name | KRYSTLE BANZUELA FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 12/05/2014
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Last Update Date | 12/05/2014
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Provider Practice Location Address
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Address Line | 6360 W 159TH ST SUITE A & B
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City | OAK FOREST
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State | IL
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Zip | 60452
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Country | US
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Telephone | 708-687-4620
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Fax |
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Provider Business Mailing Address
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Address Line | 8810 1/2 AUSTIN AVE
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City | OAK LAWN
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State | IL
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Zip | 60453
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Country | US
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Telephone | 708-655-2427
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209011993
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License Number State | IL
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