Provider Demographics
NPI:1619455474
Name:WOODSON, CRYSTAL DENISE
Entity Type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:DENISE
Last Name:WOODSON
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 1:110 GORDON RD
Mailing Address - Street 2:
Mailing Address - City:KINSALE
Mailing Address - State:VA
Mailing Address - Zip Code:22488-2138
Mailing Address - Country:US
Mailing Address - Phone:804-925-9678
Mailing Address - Fax:804-238-3146
Practice Address - Street 1:110 GORDON RD
Practice Address - Street 2:
Practice Address - City:KINSALE
Practice Address - State:VA
Practice Address - Zip Code:22488-2138
Practice Address - Country:US
Practice Address - Phone:804-925-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT67019495347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle