Provider Demographics
NPI:1962760165
Name:MEDLIN, CRYSTALLENE CELESTIAL (LMT)
Entity type:Individual
Prefix:MISS
First Name:CRYSTALLENE
Middle Name:CELESTIAL
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 E STOCK RD
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-9763
Mailing Address - Country:US
Mailing Address - Phone:360-430-1484
Mailing Address - Fax:
Practice Address - Street 1:1146 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3025
Practice Address - Country:US
Practice Address - Phone:360-577-6956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60278590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist