Provider Demographics
NPI:1558633289
Name:SMITH, CRYSTAL LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNM
Mailing Address - Street 1:262 STONES THROW AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-7016
Mailing Address - Country:US
Mailing Address - Phone:936-328-7170
Mailing Address - Fax:
Practice Address - Street 1:262 STONES THROW AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-7016
Practice Address - Country:US
Practice Address - Phone:936-328-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX671904367A00000X
TX1057136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
12586006OtherCAQH
12586006OtherCAQH