Basic Information
| Provider Information | |||||||||
| NPI: | 1689130890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FELICIANO | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1028 S SAN FERNANDO BLVD | ||||||||
| Address2: | |||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915021537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882273312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 808 W 58TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900373632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235411411 | ||||||||
| FaxNumber: | 8777207181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2019 | ||||||||
| LastUpdateDate: | 07/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP95009153 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.