Healthcare Provider Details
I. General information
NPI: 1386953461
Provider Name (Legal Business Name): CRYSTAL MARIE EDISON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 10/06/2010
Last Update Date: 08/29/2026
Certification Date: 08/29/2026
Deactivation Date:
Reactivation Date:
III. Provider practice location address
14104 NE 200TH AVE
BRUSH PRAIRIE WA
98606-3906
US
IV. Provider business mailing address
14104 NE 200TH AVE
BRUSH PRAIRIE WA
98606-3906
US
V. Phone/Fax
- Phone: 360-852-1984
- Fax:
- Phone: 360-852-1984
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | TA2910 |
| License Number State | MD |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | OEG004008 |
| License Number State | PA |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | OPT-002711 |
| License Number State | AZ |
| # 4 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 60391130 |
| License Number State | WA |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 3987-35 |
| License Number State | WI |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 18004700A |
| License Number State | IN |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 14301780-9934 |
| License Number State | UT |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | OPT003534 |
| License Number State | GA |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | TPOP146 |
| License Number State | FL |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | ATI3504 |
| License Number State | OR |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 2026038402 |
| License Number State | MO |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 152W00000X |
| Taxonomy | Optometrist |
| License Number | 1635 |
| License Number State | NE |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
