Healthcare Provider Details

I. General information

NPI: 1669868055
Provider Name (Legal Business Name): CRYSTAL LYNN MILLER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. CRYSTAL LYNN FANNIN

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 RICH RD
MORRISVILLE NY
13408
US

IV. Provider business mailing address

3305 STATE RT 46
BOUCKVILLE NY
13310
US

V. Phone/Fax

Practice location:
  • Phone: 315-893-7040
  • Fax:
Mailing address:
  • Phone: 315-893-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number316083-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: