Healthcare Provider Details

I. General information

NPI: 1568388015
Provider Name (Legal Business Name): CRYSTAL LYNN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 HUMMINGBIRD LN
INDEPENDENCE WV
26374-8516
US

IV. Provider business mailing address

122 HUMMINGBIRD LN
INDEPENDENCE WV
26374-8516
US

V. Phone/Fax

Practice location:
  • Phone: 304-980-3002
  • Fax: 304-864-4480
Mailing address:
  • Phone: 304-980-3002
  • Fax: 304-864-4480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: