Provider Demographics
NPI:1346743804
Name:LIESEKE, CRYSTAL JOANN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JOANN
Last Name:LIESEKE
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 1:10628 HEIZER DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78410-2325
Mailing Address - Country:US
Mailing Address - Phone:509-413-8858
Mailing Address - Fax:509-413-8858
Practice Address - Street 1:10628 HEIZER DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-2325
Practice Address - Country:US
Practice Address - Phone:509-413-8858
Practice Address - Fax:509-413-8858
Is Sole Proprietor?:No
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX165544164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse