Provider Demographics
NPI:1053024166
Name:MINCEY, CHRYSTAL R
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:R
Last Name:MINCEY
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 1:8744 GRASMERE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-7152
Mailing Address - Country:US
Mailing Address - Phone:252-258-0789
Mailing Address - Fax:
Practice Address - Street 1:8744 GRASMERE CT
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-7152
Practice Address - Country:US
Practice Address - Phone:252-258-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD85-2771895Medicaid