Provider Demographics
NPI:1568022523
Name:CASANOVA ENCARNACION, KRYSTAL K (APRN)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:K
Last Name:CASANOVA ENCARNACION
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:K
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1500
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:16230 SUMMERLIN RD STE 215
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-5769
Practice Address - Country:US
Practice Address - Phone:239-343-7474
Practice Address - Fax:239-343-4190
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002846363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103687500Medicaid