Provider Demographics
NPI:1447755442
Name:WEAVER-SMITH, CRYSTAL DARNELLA (CENA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DARNELLA
Last Name:WEAVER-SMITH
Suffix:
Gender:F
Credentials:CENA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 GRAND RIVER AVE UNIT 4206
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-4014
Mailing Address - Country:US
Mailing Address - Phone:313-208-0541
Mailing Address - Fax:
Practice Address - Street 1:18038 OAKFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3279
Practice Address - Country:US
Practice Address - Phone:313-208-0541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230015025640610376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide