Provider Demographics
NPI:1932771219
Name:PENLEY, KRYSTAL LYNN (LDO)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LYNN
Last Name:PENLEY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 NORTH GRADY STREET
Mailing Address - Street 2:
Mailing Address - City:PORTAL
Mailing Address - State:GA
Mailing Address - Zip Code:30450
Mailing Address - Country:US
Mailing Address - Phone:912-536-9451
Mailing Address - Fax:
Practice Address - Street 1:346 N GRADY STREET
Practice Address - Street 2:
Practice Address - City:PORTAL
Practice Address - State:GA
Practice Address - Zip Code:30450
Practice Address - Country:US
Practice Address - Phone:912-536-9451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2341156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician