Provider Demographics
NPI:1801307350
Name:PHILLIP, CRYSTAL VERNELL
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:VERNELL
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:VERNELL
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:995 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4500
Mailing Address - Country:US
Mailing Address - Phone:619-398-2156
Mailing Address - Fax:619-398-2168
Practice Address - Street 1:995 GATEWAY CENTER WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4500
Practice Address - Country:US
Practice Address - Phone:619-398-2156
Practice Address - Fax:619-398-2168
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-23
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker