Provider Demographics
NPI:1902358633
Name:RICKETT, CRYSTAL GALE (RD LD)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:GALE
Last Name:RICKETT
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 MALVERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-9638
Mailing Address - Country:US
Mailing Address - Phone:501-321-1000
Mailing Address - Fax:
Practice Address - Street 1:1910 MALVERN AVENUE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-9638
Practice Address - Country:US
Practice Address - Phone:501-321-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1049133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education