Provider Demographics
NPI:1265859417
Name:KEITH, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:KEITH
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 1:508 CACTUS CT
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-8816
Mailing Address - Country:US
Mailing Address - Phone:803-484-4180
Mailing Address - Fax:803-484-4580
Practice Address - Street 1:508 CACTUS CT
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-8816
Practice Address - Country:US
Practice Address - Phone:803-484-4180
Practice Address - Fax:803-484-4580
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92436163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health