Provider Demographics
NPI:1275835134
Name:WETZEL, CRYSTAL A (LMT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:WETZEL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1139 LIVE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3911
Mailing Address - Country:US
Mailing Address - Phone:386-547-9857
Mailing Address - Fax:
Practice Address - Street 1:821 N NOVA RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4689
Practice Address - Country:US
Practice Address - Phone:386-226-0081
Practice Address - Fax:386-226-2148
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-29
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA60861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA60861OtherMA60861