Provider Demographics
NPI:1053551531
Name:TIPPING, KRYSTAL MAE
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MAE
Last Name:TIPPING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:MAE
Other - Last Name:HANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 S 1500 W
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-4762
Mailing Address - Country:US
Mailing Address - Phone:801-710-1161
Mailing Address - Fax:801-944-3180
Practice Address - Street 1:200 S 1500 W
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-710-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-24
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT491376-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered