Provider Demographics
NPI:1912451089
Name:CARROLL, CRYSTAL ELAINE (CNA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELAINE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 E RIO GRANDE ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-4559
Mailing Address - Country:US
Mailing Address - Phone:719-722-9796
Mailing Address - Fax:
Practice Address - Street 1:826 E RIO GRANDE ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-4559
Practice Address - Country:US
Practice Address - Phone:719-722-9796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONA.00774208376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide