Provider Demographics
NPI:1861205916
Name:DOUGLAS, CRYSTAL DAWN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:DOUGLAS
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 1:185 N MAIN ST APT 29
Mailing Address - Street 2:
Mailing Address - City:PEEBLES
Mailing Address - State:OH
Mailing Address - Zip Code:45660-1267
Mailing Address - Country:US
Mailing Address - Phone:740-571-3963
Mailing Address - Fax:
Practice Address - Street 1:185 N MAIN ST APT 29
Practice Address - Street 2:
Practice Address - City:PEEBLES
Practice Address - State:OH
Practice Address - Zip Code:45660-1267
Practice Address - Country:US
Practice Address - Phone:740-571-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant