=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679287999
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL THOMPSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5003 FERN DR
-----------------------------------------------------
City | DIBERVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39540-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-749-6117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 E PASS RD
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39507-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-726-7950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246RP1900X
-----------------------------------------------------
Taxonomy Name | Phlebotomy Technician
-----------------------------------------------------
License Number | E2P2B4J4
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------