Provider Demographics
NPI:1174004535
Name:WHITE, CRYSTAL ANGELA
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANGELA
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:ANGELA
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11006 SPRING FOREST WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-4877
Mailing Address - Country:US
Mailing Address - Phone:301-503-3978
Mailing Address - Fax:
Practice Address - Street 1:11006 SPRING FOREST WAY
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-4877
Practice Address - Country:US
Practice Address - Phone:301-503-3978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD105214335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier