Healthcare Provider Details

I. General information

NPI: 1699588442
Provider Name (Legal Business Name): CRYSTAL TRINIDAD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 HARRISON ST STE 247
HILLSIDE IL
60162-1919
US

IV. Provider business mailing address

3945 W 67TH PL
CHICAGO IL
60629-4103
US

V. Phone/Fax

Practice location:
  • Phone: 312-738-3355
  • Fax:
Mailing address:
  • Phone: 773-512-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209027794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: