Provider Demographics
NPI:1679259964
Name:DISHMAN, CRYSTAL DAWN (IBCLC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:DISHMAN
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 908
Mailing Address - Street 2:
Mailing Address - City:WARNER
Mailing Address - State:OK
Mailing Address - Zip Code:74469-0908
Mailing Address - Country:US
Mailing Address - Phone:918-781-2022
Mailing Address - Fax:
Practice Address - Street 1:300 ROCKEFELLER DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5075
Practice Address - Country:US
Practice Address - Phone:918-682-5501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL-311235174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN