Healthcare Provider Details

I. General information

NPI: 1104127117
Provider Name (Legal Business Name): CRYSTAL LYNN SEVERINO NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2010
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 N RIDGE RD E STE 700A
ASHTABULA OH
44004-4300
US

IV. Provider business mailing address

1012 WATER ST
MEADVILLE PA
16335-3468
US

V. Phone/Fax

Practice location:
  • Phone: 440-484-2130
  • Fax:
Mailing address:
  • Phone: 814-333-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP023098
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0028240
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: