Healthcare Provider Details

I. General information

NPI: 1780492389
Provider Name (Legal Business Name): CRYSTAL JONES-OLALEYE FUNCTIONAL NUTRITION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2024
Last Update Date: 12/28/2024
Certification Date: 12/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 BIRCH ST
NEW IBERIA LA
70563-1906
US

IV. Provider business mailing address

408 BIRCH ST
NEW IBERIA LA
70563-1906
US

V. Phone/Fax

Practice location:
  • Phone: 337-519-5122
  • Fax:
Mailing address:
  • Phone: 337-519-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: