Provider Demographics
NPI:1730940610
Name:TATUM, CRYSTAL LEE
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:TATUM
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 1:102 E MAIN ST # UP
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:OH
Mailing Address - Zip Code:44420-2603
Mailing Address - Country:US
Mailing Address - Phone:330-469-7683
Mailing Address - Fax:
Practice Address - Street 1:102 E MAIN ST # UP
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:OH
Practice Address - Zip Code:44420-2603
Practice Address - Country:US
Practice Address - Phone:330-469-7683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide