Provider Demographics
NPI:1992519052
Name:PETTIE, CRYSTAL NICOLE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:PETTIE
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 1:1516 KENILWORTH AVE NE APT 220
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2081
Mailing Address - Country:US
Mailing Address - Phone:240-602-5323
Mailing Address - Fax:
Practice Address - Street 1:1516 KENILWORTH AVE NE APT 220
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2081
Practice Address - Country:US
Practice Address - Phone:240-602-5323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant