Healthcare Provider Details

I. General information

NPI: 1891373288
Provider Name (Legal Business Name): CRYSTAL L WOOD BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 E TOLLISON ST
BAXLEY GA
31513-0120
US

IV. Provider business mailing address

108 HATTON STILL RD LOT 4
HAZLEHURST GA
31539-4371
US

V. Phone/Fax

Practice location:
  • Phone: 912-367-9841
  • Fax:
Mailing address:
  • Phone: 912-551-2632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN204542
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: