Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0402X | Child Neurologist | 0101258310 | VA |
N | 2084N0402X | Child Neurologist | A117087 | CA |
NPI | 1013159177 |
---|---|
Provider Name | Dr. Crystal Miller Proud |
First Address | Norfolk, VA 23510-1021 |
Second Address | Norfolk, VA 23510-1021 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2009 |
Last Update Date | 19/10/2015 |