Provider Demographics
NPI:1558624155
Name:DANIELS, CRYSTAL ANNETTE (RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANNETTE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:RN
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 124
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-0124
Mailing Address - Country:US
Mailing Address - Phone:731-618-9347
Mailing Address - Fax:
Practice Address - Street 1:920 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-1605
Practice Address - Country:US
Practice Address - Phone:731-588-5829
Practice Address - Fax:731-588-5834
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000169486163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRN0000169486OtherLICENSE