Provider Demographics
NPI:1518343623
Name:WALKER, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WALKER
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 1:4090 HOMESTEAD DR APT 18
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1657
Mailing Address - Country:US
Mailing Address - Phone:818-282-6874
Mailing Address - Fax:
Practice Address - Street 1:4090 HOMESTEAD DR APT 14
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1657
Practice Address - Country:US
Practice Address - Phone:810-282-6874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI383145143372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00027285677001Medicaid
MI$$$$$$$$$OtherSOCIAL SECURITY NUMBER