Provider Demographics
NPI:1407195076
Name:GREEN, CRYSTAL MICHELLE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:GREEN
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 1:11511 BRIGIT CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4420
Mailing Address - Country:US
Mailing Address - Phone:301-880-1196
Mailing Address - Fax:
Practice Address - Street 1:11511 BRIGIT CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4420
Practice Address - Country:US
Practice Address - Phone:301-880-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-02
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide