Provider Demographics
NPI:1144510371
Name:LENZ, CRYSTAL ROSE (DO)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ROSE
Last Name:LENZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:ECCLESS INSTITUTE OF HUMAN GENETICS: 15 N MEDICAL DR RM
Mailing Address - Street 2:SPACE BASE DELTA 1
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84112
Mailing Address - Country:US
Mailing Address - Phone:801-581-2121
Mailing Address - Fax:
Practice Address - Street 1:ECCLESS INSTITUTE OF HUMAN GENETICS: 15 N MEDICAL DR RM
Practice Address - Street 2:SPACE BASE DELTA 1
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS11932208D00000X
CODR00516682083A0100X, 208D00000X
UT13891982-1204207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine