Provider Demographics
NPI:1598599821
Name:ANDERSON, CRYSTAL LAVERNE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LAVERNE
Last Name:ANDERSON
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 1:272 CALHOUN STATION PKWY STE C2131
Mailing Address - Street 2:
Mailing Address - City:GLUCKSTADT
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5540
Mailing Address - Country:US
Mailing Address - Phone:225-354-9809
Mailing Address - Fax:
Practice Address - Street 1:272 CALHOUN STATION PKWY STE C2131
Practice Address - Street 2:
Practice Address - City:GLUCKSTADT
Practice Address - State:MS
Practice Address - Zip Code:39110-5540
Practice Address - Country:US
Practice Address - Phone:225-354-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist