Provider Demographics
NPI:1811398258
Name:CLOSE, CRYSTAL LORE'
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LORE'
Last Name:CLOSE
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 1:1287 TOWNSHIP ROAD 221
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:OH
Mailing Address - Zip Code:43334-9455
Mailing Address - Country:US
Mailing Address - Phone:740-747-2408
Mailing Address - Fax:
Practice Address - Street 1:1287 TOWNSHIP ROAD 221
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:OH
Practice Address - Zip Code:43334-9455
Practice Address - Country:US
Practice Address - Phone:740-747-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0082858374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH104665690499Medicaid