Provider Demographics
NPI:1669264073
Name:WALKER, KRYSTAL LEE (LDO002421)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LEE
Last Name:WALKER
Suffix:
Gender:F
Credentials:LDO002421
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:PEARL
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LDO002421
Mailing Address - Street 1:2592 N COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-8889
Mailing Address - Country:US
Mailing Address - Phone:478-453-0800
Mailing Address - Fax:478-452-2407
Practice Address - Street 1:2592 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-8709
Practice Address - Country:US
Practice Address - Phone:478-453-0800
Practice Address - Fax:478-452-2407
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002421156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician