Provider Demographics
NPI:1093450116
Name:MIDDLETON, CRYSTAL (RD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 CENTERPOINT CIR APT 203
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2170
Mailing Address - Country:US
Mailing Address - Phone:618-201-1432
Mailing Address - Fax:
Practice Address - Street 1:1325 CENTERPOINT CIR APT 203
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2170
Practice Address - Country:US
Practice Address - Phone:618-201-1432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005204133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered