Provider Demographics
NPI:1083761431
Name:CROSSWAIT, DONNA LYNN (MED)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:LYNN
Last Name:CROSSWAIT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0333
Mailing Address - Country:US
Mailing Address - Phone:423-929-8022
Mailing Address - Fax:423-929-7344
Practice Address - Street 1:215 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-1229
Practice Address - Country:US
Practice Address - Phone:423-929-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE-0000011118101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3037884OtherBLUE CROSS