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General NPI Number Information
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NPI Number | 1992283634
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Entity Type | Individual
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Provider Name | KRYSTAL NICOLE GREEN SLPA
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Gender | Female
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Dates
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Enumeration Date | 08/03/2018
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Last Update Date | 10/18/2023
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Provider Practice Location Address
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Address Line | 549 NW LAKE WHITNEY PL STE 104
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34986-1606
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Country | US
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Telephone | 772-301-1207
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Fax |
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Provider Business Mailing Address
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Address Line | 1821 SW LEWIS ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34987-2079
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Country | US
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Telephone | 772-971-1439
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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 | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SZ11217
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number | 3394
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License Number State | FL
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