Provider Demographics
NPI:1508511692
Name:HODGE, CRYSTAL M
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:HODGE
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 1:6094 DAWSON DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY TWP
Mailing Address - State:OH
Mailing Address - Zip Code:45044-1254
Mailing Address - Country:US
Mailing Address - Phone:513-869-9322
Mailing Address - Fax:
Practice Address - Street 1:543 PARK AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-3033
Practice Address - Country:US
Practice Address - Phone:513-737-0257
Practice Address - Fax:513-737-3627
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0030756363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health