Provider Demographics
NPI:1851038244
Name:PELLEY, CRYSTAL DAWN (MS, RD, CDCES, LD)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:DAWN
Last Name:PELLEY
Suffix:
Gender:F
Credentials:MS, RD, CDCES, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-4419
Mailing Address - Country:US
Mailing Address - Phone:918-689-0055
Mailing Address - Fax:
Practice Address - Street 1:2403 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-3893
Practice Address - Country:US
Practice Address - Phone:918-218-7505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1542133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered