Provider Demographics
NPI:1376567164
Name:SHIFFERLY, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:SHIFFERLY
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 1:790 STRAUB RD W
Mailing Address - Street 2:APT. 94
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1889
Mailing Address - Country:US
Mailing Address - Phone:419-566-4012
Mailing Address - Fax:
Practice Address - Street 1:790 STRAUB RD W
Practice Address - Street 2:APT. 94
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1889
Practice Address - Country:US
Practice Address - Phone:419-566-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2168318OtherINDIVIDUAL PROVIDER