Basic Information
| Provider Information | |||||||||
| NPI: | 1982051751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRYSTAL | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | REID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REID | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1408 POMERELLE AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833182067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086776170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1408 POMERELLE AVE | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BURLEY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833182067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086776170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 35806 | ID | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 54387 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.