Provider Demographics
NPI:1548636715
Name:BAKER, KRYSTAL D (HIS)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:D
Last Name:BAKER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:D
Other - Last Name:LONGDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:775 N 1350 EAST RD
Mailing Address - Street 2:
Mailing Address - City:OWANECO
Mailing Address - State:IL
Mailing Address - Zip Code:62555-5517
Mailing Address - Country:US
Mailing Address - Phone:217-820-3462
Mailing Address - Fax:
Practice Address - Street 1:301 S WEBSTER ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2150
Practice Address - Country:US
Practice Address - Phone:217-824-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043117357164W00000X
IL3213237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No164W00000XNursing Service ProvidersLicensed Practical Nurse