Provider Demographics
NPI:1336633791
Name:GRANTHAM, CRYSTAL DALE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DALE
Last Name:GRANTHAM
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 1:210 BAY AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-9665
Mailing Address - Country:US
Mailing Address - Phone:601-788-9222
Mailing Address - Fax:601-788-6318
Practice Address - Street 1:210 BAY AVE
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476-9665
Practice Address - Country:US
Practice Address - Phone:601-788-9222
Practice Address - Fax:601-788-6318
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily