Provider Demographics
NPI:1063964757
Name:HAMILTON, CRYSTAL MICHELLE (RN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 NORTHLAKE DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-1524
Mailing Address - Country:US
Mailing Address - Phone:318-280-9819
Mailing Address - Fax:
Practice Address - Street 1:1121 NORTHLAKE DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-1524
Practice Address - Country:US
Practice Address - Phone:318-280-9819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685554163W00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse