Provider Demographics
NPI:1225863061
Name:CALLOWAY, CRYSTAL ANN
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:CALLOWAY
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:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:AR
Mailing Address - Zip Code:72921-0104
Mailing Address - Country:US
Mailing Address - Phone:479-806-5460
Mailing Address - Fax:
Practice Address - Street 1:117 E RAY FINE BLVD
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5198
Practice Address - Country:US
Practice Address - Phone:918-427-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1225863061175T00000X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes175T00000XOther Service ProvidersPeer Specialist