Provider Demographics
NPI:1902493109
Name:MANLEY, KRYSTLE
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:MANLEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:KRYSTLE
Other - Middle Name:
Other - Last Name:MANLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4673 E HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-9796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1424 W PARK LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-9653
Practice Address - Country:US
Practice Address - Phone:850-532-4616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist