Provider Demographics
NPI:1265021661
Name:BAZEMORE, CRYSTAL (BSN, RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BAZEMORE
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 WISDOM CT
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3966
Mailing Address - Country:US
Mailing Address - Phone:442-618-7172
Mailing Address - Fax:
Practice Address - Street 1:1012 WISDOM CT
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3966
Practice Address - Country:US
Practice Address - Phone:442-618-7172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR228867163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse