Provider Demographics
NPI:1578202487
Name:DUCKLO, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:DUCKLO
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 1:1425 N FAIRFIELD RD STE 110
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-2674
Mailing Address - Country:US
Mailing Address - Phone:937-426-0106
Mailing Address - Fax:937-426-7153
Practice Address - Street 1:1425 N FAIRFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2674
Practice Address - Country:US
Practice Address - Phone:937-426-0106
Practice Address - Fax:937-426-7153
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030823363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care