Healthcare Provider Details

I. General information

NPI: 1750870846
Provider Name (Legal Business Name): CRYSTAL LYN ASHBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL LYN TRANT FNP

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5514 CORPORATE DR STE 120
SAINT JOSEPH MO
64507-7754
US

IV. Provider business mailing address

5514 CORPORATE DR STE 150
SAINT JOSEPH MO
64507-7763
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-1221
  • Fax: 816-279-7794
Mailing address:
  • Phone: 816-271-1221
  • Fax: 816-279-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2018009259
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: