MEDICARE: MRS. CRYSTAL ANGEL THOMPSON

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	171400000X	Health & Wellness Coach
2	225700000X	Massage Therapist	89930	CA

General Provider Information

NPI Number	:	1659001659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL ANGEL THOMPSON

Provider Business Mailing Address
First Line	:	4464 W PROVIDENCE AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-8004
Country	:	US
Telephone Number	:	910-853-1653
Fax Number	:

Provider Business Practice Location Address
First Line	:	4464 W PROVIDENCE AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-8004
Country	:	US
Telephone Number	:	910-853-1653
Fax Number	:

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

Provider Enumeration Date	:	06/13/2022
Last Update Date	:	06/27/2022

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