Provider Demographics
NPI:1184108375
Name:ALLEN, CRYSTAL DENISE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DENISE
Last Name:ALLEN
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 1:3068 BLACKHOPE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219
Mailing Address - Country:US
Mailing Address - Phone:614-419-1313
Mailing Address - Fax:
Practice Address - Street 1:3029 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-4421
Practice Address - Country:US
Practice Address - Phone:614-419-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHIC903912174400000X, 1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No174400000XOther Service ProvidersSpecialist