Provider Demographics
NPI:1609055201
Name:HEIN, CRYSTAL LYNN (CERTIFIED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:HEIN
Suffix:
Gender:F
Credentials:CERTIFIED DIETITIAN
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:WILKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:420 E GERMAN ST
Mailing Address - Street 2:# 103A
Mailing Address - City:HERKIMER
Mailing Address - State:NY
Mailing Address - Zip Code:13350-1042
Mailing Address - Country:US
Mailing Address - Phone:315-717-2202
Mailing Address - Fax:800-891-4959
Practice Address - Street 1:420 E GERMAN ST
Practice Address - Street 2:# 103A
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-1042
Practice Address - Country:US
Practice Address - Phone:315-717-2202
Practice Address - Fax:800-892-4959
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0053821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04800005382Medicaid