Provider Demographics
NPI:1851902878
Name:BOLEN, CRYSTAL GAIL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:BOLEN
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 1:820 HAL GREER BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1713
Mailing Address - Country:US
Mailing Address - Phone:304-617-4788
Mailing Address - Fax:
Practice Address - Street 1:820 HAL GREER BLVD APT 2
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1713
Practice Address - Country:US
Practice Address - Phone:304-617-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant