Provider Demographics
NPI:1417610387
Name:GREENE, CRYSTAL LATASHA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LATASHA
Last Name:GREENE
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 1:5030 W MOUNTAIN ST APT 18
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2845
Mailing Address - Country:US
Mailing Address - Phone:678-334-4914
Mailing Address - Fax:
Practice Address - Street 1:5030 W MOUNTAIN ST APT 18
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2845
Practice Address - Country:US
Practice Address - Phone:678-334-4914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0014183784376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide