Healthcare Provider Details

I. General information

NPI: 1821312018
Provider Name (Legal Business Name): CRYSTAL WINTERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 12TH AVE
DURANT OK
74701-4718
US

IV. Provider business mailing address

22 FREEDOM ST
CALERA OK
74730-5520
US

V. Phone/Fax

Practice location:
  • Phone: 580-924-6363
  • Fax:
Mailing address:
  • Phone: 580-920-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number96665
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: