Provider Demographics
NPI:1881869238
Name:MABRY, CRYSTAL B
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:B
Last Name:MABRY
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 1:15787 COOSE HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-8966
Mailing Address - Country:US
Mailing Address - Phone:479-925-3526
Mailing Address - Fax:
Practice Address - Street 1:15787 COOSE HOLLOW DR
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-8966
Practice Address - Country:US
Practice Address - Phone:479-925-3526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR153757783Medicaid