Healthcare Provider Details

I. General information

NPI: 1043776040
Provider Name (Legal Business Name): STACI CRIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 08/22/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6855 SPRING VALLEY DR STE 110
HOLLAND OH
43528-9374
US

IV. Provider business mailing address

6855 SPRING VALLEY DR STE 110
HOLLAND OH
43528-9374
US

V. Phone/Fax

Practice location:
  • Phone: 855-659-7734
  • Fax:
Mailing address:
  • Phone: 855-659-7734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.024243
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: