Provider Demographics
NPI:1477084614
Name:MOORE, CRYSTAL BAXLEY
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:BAXLEY
Last Name:MOORE
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 1:8621 LISBON RD
Mailing Address - Street 2:
Mailing Address - City:CLARKTON
Mailing Address - State:NC
Mailing Address - Zip Code:28433-8769
Mailing Address - Country:US
Mailing Address - Phone:910-991-3151
Mailing Address - Fax:
Practice Address - Street 1:105 EAST BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337
Practice Address - Country:US
Practice Address - Phone:910-991-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC487381744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management