Provider Demographics
NPI:1114648912
Name:NELSON, CRYSTAL (CLC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1686 W ANTLER AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1917
Mailing Address - Country:US
Mailing Address - Phone:541-390-8649
Mailing Address - Fax:
Practice Address - Street 1:276 SOUND BEACH AVE FL 2
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1621
Practice Address - Country:US
Practice Address - Phone:541-390-8649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR332546174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty