Provider Demographics
NPI:1689751190
Name:GLENN, CRYSTAL LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNN
Last Name:GLENN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2526
Mailing Address - Country:US
Mailing Address - Phone:740-344-9289
Mailing Address - Fax:
Practice Address - Street 1:952 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2526
Practice Address - Country:US
Practice Address - Phone:740-344-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 111657-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2683798Medicaid