Provider Demographics
NPI:1699093021
Name:WALL, KRYSTLE E LIEBERMAN (DC, RD, LD, CBS LC)
Entity type:Individual
Prefix:DR
First Name:KRYSTLE
Middle Name:E LIEBERMAN
Last Name:WALL
Suffix:
Gender:F
Credentials:DC, RD, LD, CBS LC
Other - Prefix:DR
Other - First Name:KRYSTLE
Other - Middle Name:E
Other - Last Name:LIEBERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC, RD, LD
Mailing Address - Street 1:5801 DULUTH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-3958
Mailing Address - Country:US
Mailing Address - Phone:736-541-1280
Mailing Address - Fax:763-541-1012
Practice Address - Street 1:5801 DULUTH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-3958
Practice Address - Country:US
Practice Address - Phone:736-541-1280
Practice Address - Fax:763-541-1012
Is Sole Proprietor?:No
Enumeration Date:2010-05-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2716133V00000X
MN876171100000X
MN174N00000X
MN5317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No171100000XOther Service ProvidersAcupuncturist
No174N00000XOther Service ProvidersLactation Consultant, Non-RN