Provider Demographics
NPI:1265441414
Name:TRAVIOLI, CRYSTAL LYNN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:TRAVIOLI
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 1:1220 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-4011
Mailing Address - Country:US
Mailing Address - Phone:812-238-9871
Mailing Address - Fax:812-244-0306
Practice Address - Street 1:1220 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-4011
Practice Address - Country:US
Practice Address - Phone:812-238-9871
Practice Address - Fax:812-244-0306
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist