Provider Demographics
NPI:1154071017
Name:GUTIERREZ, CRYSTAL KAY
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:KAY
Last Name:GUTIERREZ
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 1:5015 CANYON CREST DR STE 201
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6020
Mailing Address - Country:US
Mailing Address - Phone:951-363-9806
Mailing Address - Fax:
Practice Address - Street 1:5015 CANYON CREST DR STE 201
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6020
Practice Address - Country:US
Practice Address - Phone:951-363-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9696374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty