Provider Demographics
NPI:1780913202
Name:DAVIS, KRYSTAL RAE (DC)
Entity type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:RAE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54140-2457
Mailing Address - Country:US
Mailing Address - Phone:920-462-4630
Mailing Address - Fax:920-759-5165
Practice Address - Street 1:1925 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLE CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54140-2457
Practice Address - Country:US
Practice Address - Phone:920-462-4630
Practice Address - Fax:920-759-5165
Is Sole Proprietor?:No
Enumeration Date:2009-12-11
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4559-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780913202Medicaid