MEDICARE: CRYSTAL RENE AMBERSLEY ATC, LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	A0001485	MD
2	390200000X	Student in an Organized Health Care Education/Training Program		MD

General Provider Information

NPI Number	:	1295325108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL RENE AMBERSLEY ATC, LAT

Provider Business Mailing Address
First Line	:	2319 MEADOWS CT
Second Line	:
City	:	ODENTON
State	:	MD
Zip	:	21113-4078
Country	:	US
Telephone Number	:	580-919-6424
Fax Number	:

Provider Business Practice Location Address
First Line	:	14000 JERICHO PARK RD
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20715-3319
Country	:	US
Telephone Number	:	580-919-6424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2021
Last Update Date	:	03/29/2024

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