Provider Demographics
NPI:1568187664
Name:MASSENBURG, CRYSTAL DOMINIQUE (AGENCY DIRECTOR)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DOMINIQUE
Last Name:MASSENBURG
Suffix:
Gender:F
Credentials:AGENCY DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 EMPEROR BLVD UNIT 102
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-0089
Mailing Address - Country:US
Mailing Address - Phone:919-727-0748
Mailing Address - Fax:
Practice Address - Street 1:4819 EMPEROR BLVD UNIT 102
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-0089
Practice Address - Country:US
Practice Address - Phone:919-727-0748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC6520253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care