Healthcare Provider Details

I. General information

NPI: 1780924217
Provider Name (Legal Business Name): KRYSTAL JO ETTERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTAL JO RICE

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4690 BUTLER RD
ROSEVILLE OH
43777-9719
US

IV. Provider business mailing address

420 PERINE RD
ZANESVILLE OH
43701-7641
US

V. Phone/Fax

Practice location:
  • Phone: 740-252-1934
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.374253
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN.CNP.0029903
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: