Healthcare Provider Details

I. General information

NPI: 1255650255
Provider Name (Legal Business Name): CRYSTAL ALEXANDRIA OVERBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 05/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5614 SILVER HILL RD
DISTRICT HEIGHTS MD
20747-1145
US

IV. Provider business mailing address

5614 SILVER HILL RD
DISTRICT HEIGHTS MD
20747-1145
US

V. Phone/Fax

Practice location:
  • Phone: 301-568-1112
  • Fax:
Mailing address:
  • Phone: 301-568-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number3897565
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: