Basic Information
| Provider Information | |||||||||
| NPI: | 1871028647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRIZARRY | ||||||||
| FirstName: | KRYSTLE | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | IRIZARRY | ||||||||
| OtherFirstName: | KRYSTLE | ||||||||
| OtherMiddleName: | RENEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | KRYSTLE MORRIS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 515 WEKIVA COMMONS CIR | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327123645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074649516 | ||||||||
| FaxNumber: | 4074649519 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 WEKIVA COMMONS CIR | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327123645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074649516 | ||||||||
| FaxNumber: | 4074649519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO22718 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OS15671 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.