Healthcare Provider Details

I. General information

NPI: 1679437354
Provider Name (Legal Business Name): CRYSTAL CHERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 47TH AVE
LONG ISLAND CITY NY
11101-3433
US

IV. Provider business mailing address

9229 GUY R BREWER BLVD APT 1106
JAMAICA NY
11433-2222
US

V. Phone/Fax

Practice location:
  • Phone: 718-391-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number949043
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: