Provider Demographics
NPI:1952070815
Name:ORTIZ, CRYSTAL MAIRY
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MAIRY
Last Name:ORTIZ
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 1:530 GRAY GABLES RD
Mailing Address - Street 2:
Mailing Address - City:CRAWLEY
Mailing Address - State:WV
Mailing Address - Zip Code:24931-9738
Mailing Address - Country:US
Mailing Address - Phone:304-392-6270
Mailing Address - Fax:
Practice Address - Street 1:530 GRAY GABLES RD
Practice Address - Street 2:
Practice Address - City:CRAWLEY
Practice Address - State:WV
Practice Address - Zip Code:24931-9738
Practice Address - Country:US
Practice Address - Phone:304-392-6270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant