Provider Demographics
NPI:1255876728
Name:ECKERT, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ECKERT
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 1:7908 SLAYTON SETTLEMENT RD
Mailing Address - Street 2:#9
Mailing Address - City:GASPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14067-9601
Mailing Address - Country:US
Mailing Address - Phone:720-236-6130
Mailing Address - Fax:720-862-2130
Practice Address - Street 1:7908 SLAYTON SETTLEMENT RD
Practice Address - Street 2:#9
Practice Address - City:GASPORT
Practice Address - State:NY
Practice Address - Zip Code:14067-9601
Practice Address - Country:US
Practice Address - Phone:720-236-6130
Practice Address - Fax:720-862-2130
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293312164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse