Provider Demographics
NPI:1215103296
Name:SCOTT, KRYSTAL NICHELE
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:NICHELE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:WHITMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3680 COPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-8692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3680 COPPER RIDGE DR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-8692
Practice Address - Country:US
Practice Address - Phone:951-734-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7960363L00000X
CA472159163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse