Healthcare Provider Details

I. General information

NPI: 1700553401
Provider Name (Legal Business Name): CRYSTAL M STALLWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 FARM PATH
ROSWELL GA
30075-4219
US

IV. Provider business mailing address

330 FARM PATH
ROSWELL GA
30075-4219
US

V. Phone/Fax

Practice location:
  • Phone: 404-997-0167
  • Fax:
Mailing address:
  • Phone: 404-997-0167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: