Provider Demographics
NPI:1154674646
Name:NELISSE, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:NELISSE
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 1:465 LODI ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-3171
Mailing Address - Country:US
Mailing Address - Phone:330-752-3543
Mailing Address - Fax:
Practice Address - Street 1:465 LODI ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-3171
Practice Address - Country:US
Practice Address - Phone:330-752-3543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-21
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH40146130910376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide