Provider Demographics
NPI:1215524905
Name:PENDLETON, CRYSTAL LEANN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEANN
Last Name:PENDLETON
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 1:318 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1038
Mailing Address - Country:US
Mailing Address - Phone:740-418-7722
Mailing Address - Fax:
Practice Address - Street 1:318 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1038
Practice Address - Country:US
Practice Address - Phone:740-418-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSH677096172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No172A00000XOther Service ProvidersDriver