Healthcare Provider Details

I. General information

NPI: 1063445039
Provider Name (Legal Business Name): CRYSTAL ROMAY R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 N FREMONT AVE
SPRINGFIELD MO
65802-3511
US

IV. Provider business mailing address

1110 N FREMONT AVE
SPRINGFIELD MO
65802-3511
US

V. Phone/Fax

Practice location:
  • Phone: 417-865-9090
  • Fax: 417-864-3226
Mailing address:
  • Phone: 417-865-9090
  • Fax: 417-864-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number130327
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: