Provider Demographics
NPI:1144502923
Name:LEAL, CRYSTAL CORRINE (BA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:CORRINE
Last Name:LEAL
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:CORRINE
Other - Last Name:O'CONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:624 S. 13TH ST.
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-749-2881
Mailing Address - Fax:218-749-3806
Practice Address - Street 1:624 S. 13TH ST.
Practice Address - Street 2:
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-749-2881
Practice Address - Fax:218-749-3806
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program