1013498526 NPI number — JOAN KRYSTYNIAK-COLLINS OTR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013498526 NPI number — JOAN KRYSTYNIAK-COLLINS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRYSTYNIAK-COLLINS
Provider First Name:
JOAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013498526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11517 COUNTY ROAD 917
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76035-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-578-7479
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1019 HOLDEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ROSE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76043-4937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-578-7479
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XG0600X , with the licence number:  100823 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100823 . This is a "OT LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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