Healthcare Provider Details

I. General information

NPI: 1740722859
Provider Name (Legal Business Name): CRYSTAL BRANAN RAINES NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2016
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-3508
  • Fax:
Mailing address:
  • Phone: 904-244-3508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number9438366
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number9438366
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: