Healthcare Provider Details

I. General information

NPI: 1689247405
Provider Name (Legal Business Name): CRYSTAL A HEARN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 KIRKWOOD HWY STE 101
WILMINGTON DE
19805-4939
US

IV. Provider business mailing address

1702 KIRKWOOD HWY STE 101
WILMINGTON DE
19805-4939
US

V. Phone/Fax

Practice location:
  • Phone: 302-777-0778
  • Fax:
Mailing address:
  • Phone: 302-777-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-0015110
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: