Provider Demographics
NPI:1275154338
Name:EDWARDS, CRYSTAL
Entity Type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYS
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2018 RED OAK DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-9327
Mailing Address - Country:US
Mailing Address - Phone:601-842-9662
Mailing Address - Fax:
Practice Address - Street 1:2718 MEDGAR EVERS BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7257
Practice Address - Country:US
Practice Address - Phone:601-842-9662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist