Provider Demographics
NPI:1487104808
Name:DIXON, KRYSTLE
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:DIXON
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 1:1948 OLD OCILLA RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1644
Mailing Address - Country:US
Mailing Address - Phone:229-391-3500
Mailing Address - Fax:
Practice Address - Street 1:15 S RAILROAD ST
Practice Address - Street 2:
Practice Address - City:LENOX
Practice Address - State:GA
Practice Address - Zip Code:31637-7424
Practice Address - Country:US
Practice Address - Phone:229-546-4206
Practice Address - Fax:229-546-4612
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216493363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology