Provider Demographics
NPI:1366802027
Name:MCKINNISS, CRYSTAL A (LPN)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:A
Last Name:MCKINNISS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:SAMARITAN BEHAVIORAL HEALTH INC, 4TH FLOOR NW BLDG
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-734-4343
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:SAMARITAN BEHAVIORAL HEALTH INC.,
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.507286163WP0808X
OHPN.122329-M-IV167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician