Provider Demographics
NPI:1669563292
Name:TAINTER, CRYSTAL DAWN (PT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:TAINTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:DAWN
Other - Last Name:WILLCOXEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:11225 ULYSSES ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4261
Mailing Address - Country:US
Mailing Address - Phone:763-302-2600
Mailing Address - Fax:763-302-2601
Practice Address - Street 1:11225 ULYSSES ST NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4261
Practice Address - Country:US
Practice Address - Phone:763-302-2600
Practice Address - Fax:763-302-2601
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist