Basic Information
| Provider Information | |||||||||
| NPI: | 1073093704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALACIOS | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | LVN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12915 HUECO SANDS DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799385247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157300154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 221 N KANSAS ST STE 744 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799011443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152131289 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 338183 | TX | Y | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1952346876 | 01 | HOME HEALTH | OTHER |