Provider Demographics
NPI:1245787449
Name:WILSON, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WILSON
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 1:1031 WILMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TURKEY
Mailing Address - State:NC
Mailing Address - Zip Code:28393-8405
Mailing Address - Country:US
Mailing Address - Phone:910-379-3675
Mailing Address - Fax:
Practice Address - Street 1:1031 WILMINGTON RD
Practice Address - Street 2:
Practice Address - City:TURKEY
Practice Address - State:NC
Practice Address - Zip Code:28393-8405
Practice Address - Country:US
Practice Address - Phone:910-379-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82000291174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist