Healthcare Provider Details

I. General information

NPI: 1386378719
Provider Name (Legal Business Name): CRYSTAL MCNACK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 E EASTLAND CENTER CT STE 200
INDEPENDENCE MO
64055-7023
US

IV. Provider business mailing address

4840 OVERTON AVE
KANSAS CITY MO
64133-1821
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-9299
  • Fax:
Mailing address:
  • Phone: 816-210-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number2018006875
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: