Provider Demographics
NPI:1871341073
Name:ST. FORT, CRYSTAL (NP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ST. FORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 S 60TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-3038
Mailing Address - Country:US
Mailing Address - Phone:215-495-5846
Mailing Address - Fax:
Practice Address - Street 1:142 S 60TH ST UNIT A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3038
Practice Address - Country:US
Practice Address - Phone:215-495-5846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP029428207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty