Provider Demographics
NPI:1578046819
Name:NEWVINE, CRYSTAL-ANDREA LISETTE
Entity type:Individual
Prefix:
First Name:CRYSTAL-ANDREA
Middle Name:LISETTE
Last Name:NEWVINE
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 1:508 1/2 E COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2021
Mailing Address - Country:US
Mailing Address - Phone:714-818-9787
Mailing Address - Fax:
Practice Address - Street 1:2390 E ORANGEWOOD AVE STE 300
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-6138
Practice Address - Country:US
Practice Address - Phone:714-742-2681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator