MEDICARE: KRYSTALL GREENWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1093356131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTALL GREENWELL

Provider Business Mailing Address
First Line	:	410 N GENEVA RD
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84601-1253
Country	:	US
Telephone Number	:	512-629-2065
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 SMITH FIELD HOUSE
Second Line	:	BRIGHAM YOUNG UNIVERSITY
City	:	PROVO
State	:	UT
Zip	:	84604-8460
Country	:	US
Telephone Number	:	801-422-2946
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2019
Last Update Date	:	09/30/2019

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Directions to “ KRYSTALL GREENWELL ” Practice Location

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