1134872245 NPI number — CRYSTAL RAE CLENDENNEN PEIRCE DO

Table of content: DR. KHA DINH NGUYEN PHARMD (NPI 1548897184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134872245 NPI number — CRYSTAL RAE CLENDENNEN PEIRCE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLENDENNEN PEIRCE
Provider First Name:
CRYSTAL
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEIRCE
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
CLENDENNEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1134872245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 PORTERFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTER
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04068-3636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-425-2766
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
677 CHURCH ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-573-6181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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