Healthcare Provider Details

I. General information

NPI: 1922690247
Provider Name (Legal Business Name): CRYSTAL CHEYENNE WEATHERFORD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL CHEYENNE COUEY

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 BIRDCREEK TER
TEMPLE TX
76502-1047
US

IV. Provider business mailing address

51748 HOPI ST APT 1
FORT HOOD TX
76544-1358
US

V. Phone/Fax

Practice location:
  • Phone: 254-771-0852
  • Fax:
Mailing address:
  • Phone: 214-476-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1018430
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: