Provider Demographics
NPI:1073862876
Name:WHITE, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WHITE
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 1:769 PLAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02050-2118
Mailing Address - Country:US
Mailing Address - Phone:617-847-1950
Mailing Address - Fax:617-774-1490
Practice Address - Street 1:769 PLAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:MA
Practice Address - Zip Code:02050-2118
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN285279363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health