MEDICARE: CHRYSTAL CRAFT APNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	10182	WI
2	363L00000X	Nurse Practitioner	10182	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679194278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRYSTAL CRAFT APNP

Provider Business Mailing Address
First Line	:	PO BOX 735044
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60673-5044
Country	:	US
Telephone Number	:	800-326-2250
Fax Number	:

Provider Business Practice Location Address
First Line	:	2801 W KINNICKINNIC RIVER PKWY STE 380
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-3632
Country	:	US
Telephone Number	:	414-649-3370
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2020
Last Update Date	:	05/12/2025

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