Provider Demographics
NPI:1770225229
Name:GOSS, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:GOSS
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 1:111 ROAD 3000
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-9501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 S PARK AVE
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2253
Practice Address - Country:US
Practice Address - Phone:505-334-9469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86330163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty