Provider Demographics
NPI:1386892727
Name:NICHOLS, CRYSTAL PATRESE
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:PATRESE
Last Name:NICHOLS
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 1:5783 EDMONDS WAY
Mailing Address - Street 2:
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-7414
Mailing Address - Country:US
Mailing Address - Phone:661-824-4350
Mailing Address - Fax:
Practice Address - Street 1:15662 K ST
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1826
Practice Address - Country:US
Practice Address - Phone:661-824-4118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator