Provider Demographics
NPI:1104496553
Name:NELSON, KRYSTAL S (LPN)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:S
Last Name:NELSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 RASKOB ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-3329
Mailing Address - Country:US
Mailing Address - Phone:810-969-7319
Mailing Address - Fax:
Practice Address - Street 1:2420 RASKOB ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-3329
Practice Address - Country:US
Practice Address - Phone:810-969-7319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703122625164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse