Provider Demographics
NPI:1003986274
Name:PROULX, CRYSTAL ANN (MSRD, LD, CNSD)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:PROULX
Suffix:
Gender:F
Credentials:MSRD, LD, CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BOW BOG RD
Mailing Address - Street 2:
Mailing Address - City:BOW
Mailing Address - State:NH
Mailing Address - Zip Code:03304-4300
Mailing Address - Country:US
Mailing Address - Phone:603-228-4764
Mailing Address - Fax:
Practice Address - Street 1:100 MCGREGOR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3730
Practice Address - Country:US
Practice Address - Phone:603-663-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH162133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered