Healthcare Provider Details

I. General information

NPI: 1801307350
Provider Name (Legal Business Name): MRS. CRYSTAL VERNELL PHILLIP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL VERNELL TAYLOR

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4500
US

IV. Provider business mailing address

995 GATEWAY CENTER WAY
SAN DIEGO CA
92102-4500
US

V. Phone/Fax

Practice location:
  • Phone: 619-398-2156
  • Fax: 619-398-2168
Mailing address:
  • Phone: 619-398-2156
  • Fax: 619-398-2168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: