Provider Demographics
NPI:1659001659
Name:THOMPSON, CRYSTAL ANGEL
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANGEL
Last Name:THOMPSON
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 1:4464 W PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8004
Mailing Address - Country:US
Mailing Address - Phone:910-853-1653
Mailing Address - Fax:
Practice Address - Street 1:4464 W PROVIDENCE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-8004
Practice Address - Country:US
Practice Address - Phone:910-853-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
CA89930225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach