Provider Demographics
NPI:1003060815
Name:WALLENTINE, CRYSTAL BRENNEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:BRENNEN
Last Name:WALLENTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 E SAINT MARYS DR
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2245
Mailing Address - Country:US
Mailing Address - Phone:801-865-0549
Mailing Address - Fax:
Practice Address - Street 1:1937 E SAINT MARYS DR
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84108-2245
Practice Address - Country:US
Practice Address - Phone:801-865-0549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2023-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3613633-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine