Provider Demographics
NPI:1720543382
Name:CANTERBURY, CRYSTAL DAWN (RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:CANTERBURY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 RIGHT FORK LAUREL CRK
Mailing Address - Street 2:
Mailing Address - City:LENORE
Mailing Address - State:WV
Mailing Address - Zip Code:25676-7010
Mailing Address - Country:US
Mailing Address - Phone:304-235-3333
Mailing Address - Fax:
Practice Address - Street 1:1 RANGER DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-9165
Practice Address - Country:US
Practice Address - Phone:304-235-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV60059163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool