Provider Demographics
NPI:1023763463
Name:LANDERS, CRYSTAL GAIL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:LANDERS
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 13171
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25360-0171
Mailing Address - Country:US
Mailing Address - Phone:304-984-9591
Mailing Address - Fax:
Practice Address - Street 1:7 MERCATOR WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-5349
Practice Address - Country:US
Practice Address - Phone:304-984-9591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant