Provider Demographics
NPI:1790139095
Name:FACKELMAN, CRYSTAL (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:FACKELMAN
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 1:1 BARRINGER DR
Mailing Address - Street 2:
Mailing Address - City:HAMLIN
Mailing Address - State:NY
Mailing Address - Zip Code:14464-9303
Mailing Address - Country:US
Mailing Address - Phone:585-369-4145
Mailing Address - Fax:
Practice Address - Street 1:1 BARRINGER DR
Practice Address - Street 2:
Practice Address - City:HAMLIN
Practice Address - State:NY
Practice Address - Zip Code:14464-9303
Practice Address - Country:US
Practice Address - Phone:585-369-4145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296090164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse