Basic Information
| Provider Information | |||||||||
| NPI: | 1538775390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCNALLY | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 W PINE AVE STE B20 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088122287 | ||||||||
| FaxNumber: | 8889902969 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 W PINE AVE STE B20 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836422412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082868670 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2020 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363L00000X | 202008407NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.