Provider Demographics
NPI:1821541699
Name:CONKLIN, CRYSTAL (MSOT OTR/L)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:MSOT OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 VANGUARD DR
Mailing Address - Street 2:
Mailing Address - City:RED HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18076-1491
Mailing Address - Country:US
Mailing Address - Phone:267-280-7333
Mailing Address - Fax:
Practice Address - Street 1:940 VANGUARD DR
Practice Address - Street 2:
Practice Address - City:RED HILL
Practice Address - State:PA
Practice Address - Zip Code:18076-1491
Practice Address - Country:US
Practice Address - Phone:267-280-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013968171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor