Provider Demographics
NPI:1184915753
Name:TAYLOR, CRYSTAL DIANNE (DO)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DIANNE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 NE SAINT LUKES BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6001
Mailing Address - Country:US
Mailing Address - Phone:816-282-7809
Mailing Address - Fax:816-282-7870
Practice Address - Street 1:20 NE SAINT LUKES BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6001
Practice Address - Country:US
Practice Address - Phone:816-282-7809
Practice Address - Fax:816-282-7870
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-29
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019206207V00000X
MO2015014688207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA62000007Medicare UPIN