Provider Demographics
NPI:1518294529
Name:MCINTOSH, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MCINTOSH
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 1:199 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1809
Mailing Address - Country:US
Mailing Address - Phone:516-377-6304
Mailing Address - Fax:
Practice Address - Street 1:199 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1809
Practice Address - Country:US
Practice Address - Phone:516-377-6304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-11
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299174164W00000X
NY713199163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse