Provider Demographics
NPI:1144836651
Name:WIEDL, CRYSTAL RENAY
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENAY
Last Name:WIEDL
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 1:6085 STONEY FORK RD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-5803
Mailing Address - Country:US
Mailing Address - Phone:276-620-0961
Mailing Address - Fax:
Practice Address - Street 1:222 FULCHER ST
Practice Address - Street 2:
Practice Address - City:HILLSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24343-1633
Practice Address - Country:US
Practice Address - Phone:276-728-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-20
Last Update Date:2020-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605452225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant