Provider Demographics
NPI:1417772161
Name:RODRIGUEZ, KRYSTLE
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 MURRAY DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3339
Mailing Address - Country:US
Mailing Address - Phone:209-926-9042
Mailing Address - Fax:209-762-6809
Practice Address - Street 1:545 W SONORA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-3329
Practice Address - Country:US
Practice Address - Phone:209-888-9086
Practice Address - Fax:209-762-6806
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker