Provider Demographics
NPI:1982256764
Name:GINGRAS, CRYSTAL DONIELLE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DONIELLE
Last Name:GINGRAS
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:PO BOX 4301
Mailing Address - Street 2:
Mailing Address - City:HAGATNA
Mailing Address - State:GU
Mailing Address - Zip Code:96932-8301
Mailing Address - Country:US
Mailing Address - Phone:671-788-1980
Mailing Address - Fax:
Practice Address - Street 1:382 TAI GIGAO RD
Practice Address - Street 2:
Practice Address - City:AGANA HEIGHTS
Practice Address - State:GU
Practice Address - Zip Code:96910-6133
Practice Address - Country:US
Practice Address - Phone:671-788-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU13-201401340-001225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist