Provider Demographics
NPI:1770813016
Name:CRYSTAL E. NICKERSON
Entity type:Organization
Organization Name:CRYSTAL E. NICKERSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-508-8190
Mailing Address - Street 1:2302 W. MEADOWVIEW ROAD SUITE 228; BOX 24
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-6012
Mailing Address - Country:US
Mailing Address - Phone:336-218-5176
Mailing Address - Fax:336-854-0279
Practice Address - Street 1:2302 W. MEADOWVIEW ROAD SUITE 228
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-6012
Practice Address - Country:US
Practice Address - Phone:336-218-5176
Practice Address - Fax:336-854-0279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1770813016Medicaid