Healthcare Provider Details

I. General information

NPI: 1275995607
Provider Name (Legal Business Name): CRYSTAL RENEE GILLESPIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 05/07/2024
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17010 CHATSWORTH ST
GRANADA HILLS CA
91344-5844
US

IV. Provider business mailing address

FILE 50670
LOS ANGELES CA
90074-0670
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax:
Mailing address:
  • Phone: 888-227-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: