Healthcare Provider Details

I. General information

NPI: 1548834625
Provider Name (Legal Business Name): CRYSTAL WISE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 TUGGLE RD
PROSPECT VA
23960-7919
US

IV. Provider business mailing address

520 TUGGLE RD
PROSPECT VA
23960-7919
US

V. Phone/Fax

Practice location:
  • Phone: 434-509-5235
  • Fax: 434-223-1423
Mailing address:
  • Phone: 434-509-5235
  • Fax: 434-223-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001290756
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: