Provider Demographics
NPI:1902626237
Name:SMITH, CRYSTAL DENISE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DENISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:DENISE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:203 N GRAND ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-1344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 N GRAND ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-1344
Practice Address - Country:US
Practice Address - Phone:573-218-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024018507163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)