Provider Demographics
NPI:1518022888
Name:BREEZE, CRYSTAL W
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:W
Last Name:BREEZE
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 4174
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-0902
Mailing Address - Country:US
Mailing Address - Phone:336-513-6532
Mailing Address - Fax:
Practice Address - Street 1:162 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:NC
Practice Address - Zip Code:27253-2808
Practice Address - Country:US
Practice Address - Phone:336-513-6532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3207251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601438Medicaid
NC3418139Medicaid