Provider Demographics
NPI:1679186266
Name:BOLDEN, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BOLDEN
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 1:126 LITTLE DAVY RD
Mailing Address - Street 2:
Mailing Address - City:DAVY
Mailing Address - State:WV
Mailing Address - Zip Code:24828-9776
Mailing Address - Country:US
Mailing Address - Phone:304-656-7282
Mailing Address - Fax:
Practice Address - Street 1:126 LITTLE DAVY RD
Practice Address - Street 2:
Practice Address - City:DAVY
Practice Address - State:WV
Practice Address - Zip Code:24828-9776
Practice Address - Country:US
Practice Address - Phone:304-656-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant