Provider Demographics
NPI:1619856473
Name:PENN, KRYSTA
Entity type:Individual
Prefix:
First Name:KRYSTA
Middle Name:
Last Name:PENN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTA
Other - Middle Name:
Other - Last Name:LATHON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:506 MALCOLM AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-2535
Mailing Address - Country:US
Mailing Address - Phone:502-271-8486
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2535
Practice Address - Country:US
Practice Address - Phone:502-271-8486
Practice Address - Fax:502-271-8486
Is Sole Proprietor?:No
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1159364163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse