Provider Demographics
NPI:1902566193
Name:LEBLANC, KRYSTAL F (CHW)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:F
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2459 SE TUALATIN VALLEY HWY # 416
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-7919
Mailing Address - Country:US
Mailing Address - Phone:503-972-0235
Mailing Address - Fax:
Practice Address - Street 1:1427 NW FLANDERS ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2646
Practice Address - Country:US
Practice Address - Phone:503-972-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR105948172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker