=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700254299
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTLE ALINE KRAFT HAD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2015
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1151 S LA CANADA DR
-----------------------------------------------------
City | GREEN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85614-1943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-407-6005
-----------------------------------------------------
Fax | 520-407-6273
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8800 SE SUNNYSIDE RD STE 300N
-----------------------------------------------------
City | CLACKAMAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97015-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-286-2999
-----------------------------------------------------
Fax | 512-607-4893
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | THAD9200
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------