Provider Demographics
NPI:1467014894
Name:CLARK, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CLARK
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:PO BOX 64283
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-6683
Mailing Address - Country:US
Mailing Address - Phone:404-321-2852
Mailing Address - Fax:
Practice Address - Street 1:153 BRAMBURY DR APT D
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-1820
Practice Address - Country:US
Practice Address - Phone:404-621-2852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYGA0401903R376K00000X
372600000X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide
No372500000XNursing Service Related ProvidersChore Provider