Provider Demographics
NPI:1679013486
Name:LOPEZ, KRYSTAL (APRN)
Entity type:Individual
Prefix:MRS
First Name:KRYSTAL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:WYNTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-7611
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:3661 S BABCOCK ST FL 2
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8205
Practice Address - Country:US
Practice Address - Phone:321-434-7611
Practice Address - Fax:321-727-3738
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9314840363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLKN043OtherMEDICARE
FL101310900Medicaid
FLKN043OtherMEDICARE