Healthcare Provider Details

I. General information

NPI: 1427760297
Provider Name (Legal Business Name): CRYSTAL R HINES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2022
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 RIDGEVIEW DR
MOUNT LOOKOUT WV
26678-9405
US

IV. Provider business mailing address

1550 RIDGEVIEW DR
MOUNT LOOKOUT WV
26678-9405
US

V. Phone/Fax

Practice location:
  • Phone: 304-678-3644
  • Fax:
Mailing address:
  • Phone: 304-678-3644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number110533
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: