Provider Demographics
NPI:1033617675
Name:MOORE, CRYSTAL CHANTEL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CHANTEL
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 PAR LN
Mailing Address - Street 2:H 911
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-2966
Mailing Address - Country:US
Mailing Address - Phone:910-546-7997
Mailing Address - Fax:
Practice Address - Street 1:2260 PAR LN
Practice Address - Street 2:H 911
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-2966
Practice Address - Country:US
Practice Address - Phone:910-546-7997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161915164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse