Provider Demographics
NPI:1063057446
Name:HALLER, KRYSTALE A
Entity type:Individual
Prefix:
First Name:KRYSTALE
Middle Name:A
Last Name:HALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S PITTSBURGH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-3512
Mailing Address - Country:US
Mailing Address - Phone:724-802-5595
Mailing Address - Fax:
Practice Address - Street 1:304 S PITTSBURGH ST APT 1
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3512
Practice Address - Country:US
Practice Address - Phone:724-802-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA43963601253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care