MEDICARE: MISS KRYSTAL MARIE LEE LPN

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	164W00000X	Licensed Practical Nurse		WI

General Provider Information

NPI Number	:	1225058894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KRYSTAL MARIE LEE LPN

Provider Business Mailing Address
First Line	:	1839 N.47 TH STREET
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1710
Country	:	US
Telephone Number	:	414-475-9868
Fax Number	:

Provider Business Practice Location Address
First Line	:	1839 N.47 STREET
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1710
Country	:	US
Telephone Number	:	414-475-9868
Fax Number	:

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	07/12/2007

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