Healthcare Provider Details

I. General information

NPI: 1154955334
Provider Name (Legal Business Name): CRYSTAL LYNN COLE PMHNP-BC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 W BRADLEY PL STE 100
CHICAGO IL
60618-4716
US

IV. Provider business mailing address

PO BOX 506
NORTHBROOK IL
60065-0506
US

V. Phone/Fax

Practice location:
  • Phone: 224-306-1879
  • Fax: 224-205-3757
Mailing address:
  • Phone: 847-562-9505
  • Fax: 847-282-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL LYNN COLE
Title or Position: OWNER
Credential: PMHNP
Phone: 224-306-1879