Provider Demographics
NPI:1861007023
Name:ACOSTA, CRYSTAL CHRISTINE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CHRISTINE
Last Name:ACOSTA
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 1:30374 MONTE VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:THOUSAND PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92276-2939
Mailing Address - Country:US
Mailing Address - Phone:760-219-9137
Mailing Address - Fax:
Practice Address - Street 1:151 S SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-0118
Practice Address - Country:US
Practice Address - Phone:760-834-3593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA688903164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse