Provider Demographics
NPI:1699262691
Name:ICENHOUR, CRYSTAL (PHD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:ICENHOUR
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45925 HORSESHOE DR STE 170
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-6609
Mailing Address - Country:US
Mailing Address - Phone:703-229-0406
Mailing Address - Fax:
Practice Address - Street 1:45925 HORSESHOE DR STE 170
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-6609
Practice Address - Country:US
Practice Address - Phone:703-229-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACLF0001793207SG0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0205XAllopathic & Osteopathic PhysiciansMedical GeneticsPh.D. Medical Genetics