Provider Demographics
NPI:1548668601
Name:BANZUELA, KRYSTLE (FNP-BC)
Entity type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:
Last Name:BANZUELA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8810 1/2 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-655-2427
Mailing Address - Fax:
Practice Address - Street 1:6360 W 159TH ST
Practice Address - Street 2:SUITE A & B
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452
Practice Address - Country:US
Practice Address - Phone:708-687-4620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209011993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily