Provider Demographics
NPI:1225497126
Name:PACE, CRYSTAL MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:PACE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:MICHELLE
Other - Last Name:CASCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:667 CONGRESS ST APT 302
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5171
Mailing Address - Country:US
Mailing Address - Phone:914-469-7804
Mailing Address - Fax:
Practice Address - Street 1:667 CONGRESS ST APT 302
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5171
Practice Address - Country:US
Practice Address - Phone:914-469-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-19
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86050249133V00000X
NY009044-1133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered