Provider Demographics
NPI:1346014750
Name:ARCHULETA, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ARCHULETA
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 1:1990 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-3112
Mailing Address - Country:US
Mailing Address - Phone:575-740-5674
Mailing Address - Fax:
Practice Address - Street 1:900 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-6600
Practice Address - Country:US
Practice Address - Phone:575-740-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker