Provider Demographics
NPI:1639954373
Name:MARTIN, CRYSTAL JILNEA (PTA)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:JILNEA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 MARTHA LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234-2568
Mailing Address - Country:US
Mailing Address - Phone:202-664-2864
Mailing Address - Fax:
Practice Address - Street 1:12725 STONE VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2722
Practice Address - Country:US
Practice Address - Phone:804-245-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant