Provider Demographics
NPI:1821609090
Name:MORAN, CRYSTAL R
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:R
Last Name:MORAN
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 1:134 S MAIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-1797
Mailing Address - Country:US
Mailing Address - Phone:304-257-8820
Mailing Address - Fax:
Practice Address - Street 1:1642 ELKHORN RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-8717
Practice Address - Country:US
Practice Address - Phone:304-257-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant