Provider Demographics
NPI:1225629264
Name:DEER-WALKER, CRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:DEER-WALKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-4005
Mailing Address - Country:US
Mailing Address - Phone:601-996-0455
Mailing Address - Fax:
Practice Address - Street 1:114 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-4005
Practice Address - Country:US
Practice Address - Phone:769-204-3488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS336930164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse