1114535150 NPI number — MRS. CRYSTAL LOUISE GREEN

Table of content: MRS. CRYSTAL LOUISE GREEN (NPI 1114535150)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114535150 NPI number — MRS. CRYSTAL LOUISE GREEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
CRYSTAL
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BURNS
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114535150
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19206 21ST ST SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEBAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98349-9280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
125-329-2888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 W COTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98584-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-839-2822
Provider Business Practice Location Address Fax Number:
360-839-2822
Provider Enumeration Date:
07/15/2020

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100000034753 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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