Provider Demographics
NPI:1376215723
Name:CUNNING, CRYSTAL C
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:C
Last Name:CUNNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:C
Other - Last Name:MILLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10038 MEADOW WAY UNIT D
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-4974
Mailing Address - Country:US
Mailing Address - Phone:530-426-2110
Mailing Address - Fax:
Practice Address - Street 1:10038 MEADOW WAY UNIT D
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4974
Practice Address - Country:US
Practice Address - Phone:530-426-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-LBFNXT175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker