Provider Demographics
NPI:1821615428
Name:BOLTON, CRYSTAL (LVN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 VIENNA BEND DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-2830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 E PLEASANT RUN RD APT 1602
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4248
Practice Address - Country:US
Practice Address - Phone:318-787-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-30
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332849164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty