1609055201 NPI number — MS. CRYSTAL LYNN HEIN CERTIFIED DIETITIAN

Table of content: MS. CRYSTAL LYNN HEIN CERTIFIED DIETITIAN (NPI 1609055201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609055201 NPI number — MS. CRYSTAL LYNN HEIN CERTIFIED DIETITIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEIN
Provider First Name:
CRYSTAL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED DIETITIAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILKINS
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609055201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 E GERMAN ST
Provider Second Line Business Mailing Address:
# 103A
Provider Business Mailing Address City Name:
HERKIMER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13350-1042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-717-2202
Provider Business Mailing Address Fax Number:
800-891-4959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 E GERMAN ST
Provider Second Line Business Practice Location Address:
# 103A
Provider Business Practice Location Address City Name:
HERKIMER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13350-1042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-717-2202
Provider Business Practice Location Address Fax Number:
800-892-4959
Provider Enumeration Date:
10/31/2007

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: 133V00000X , with the licence number:  0053821 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 04800005382 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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