Provider Demographics
NPI:1942755202
Name:VALENTINE, CRYSTAL (STUDENT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 BRASSFIELD DR
Mailing Address - Street 2:APT 203
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-2677
Mailing Address - Country:US
Mailing Address - Phone:336-408-1470
Mailing Address - Fax:
Practice Address - Street 1:4455 BRASSFIELD DR
Practice Address - Street 2:APT 203
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-2677
Practice Address - Country:US
Practice Address - Phone:336-408-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23711702390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program