Basic Information
| Provider Information | |||||||||
| NPI: | 1760777916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KRYSTLE | ||||||||
| MiddleName: | B | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EMISON | ||||||||
| OtherFirstName: | KRYSTLE | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1004 | ||||||||
| Address2: | |||||||||
| City: | MILAN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383581004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3161322147 | ||||||||
| FaxNumber: | 7316132215 | ||||||||
| Practice Location | |||||||||
| Address1: | 2060 RHINO XING | ||||||||
| Address2: | |||||||||
| City: | MILAN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383585201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316132214 | ||||||||
| FaxNumber: | 7316132215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2011 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.