Provider Demographics
NPI:1235825308
Name:WADE, CRYSTAL AMANDA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMANDA
Last Name:WADE
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 1:1551 DODGE WAY
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-3885
Mailing Address - Country:US
Mailing Address - Phone:626-633-7854
Mailing Address - Fax:
Practice Address - Street 1:12023 3RD ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2743
Practice Address - Country:US
Practice Address - Phone:626-633-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker