Provider Demographics
NPI:1194514125
Name:SAMUEL, KRYSTAL ABYGAYLE
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ABYGAYLE
Last Name:SAMUEL
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 1:30 WATERS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-5035
Mailing Address - Country:US
Mailing Address - Phone:516-492-1786
Mailing Address - Fax:
Practice Address - Street 1:30 WATERS EDGE LN
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-5035
Practice Address - Country:US
Practice Address - Phone:516-492-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program