Provider Demographics
NPI:1801934666
Name:CRUMMETT, IMELDA R (LVN)
Entity type:Individual
Prefix:MRS
First Name:IMELDA
Middle Name:R
Last Name:CRUMMETT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 OGLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIO DELL
Mailing Address - State:CA
Mailing Address - Zip Code:95562-1013
Mailing Address - Country:US
Mailing Address - Phone:707-764-5089
Mailing Address - Fax:
Practice Address - Street 1:218 OGLE AVE
Practice Address - Street 2:
Practice Address - City:RIO DELL
Practice Address - State:CA
Practice Address - Zip Code:95562-1013
Practice Address - Country:US
Practice Address - Phone:707-764-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN135430164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN001000OtherRVN
CAEPS012410OtherEPS