Provider Demographics
NPI:1740951292
Name:WONDERLY, CRYSTAL ANN
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:WONDERLY
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 1:707 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-1664
Mailing Address - Country:US
Mailing Address - Phone:419-619-2799
Mailing Address - Fax:
Practice Address - Street 1:707 W PARK DR
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1664
Practice Address - Country:US
Practice Address - Phone:419-619-2799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant