Healthcare Provider Details

I. General information

NPI: 1760084651
Provider Name (Legal Business Name): CRYSTAL WARD FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 10/30/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 SE POWELL VALLEY RD
GRESHAM OR
97080-1494
US

IV. Provider business mailing address

PO BOX 3777
PORTLAND OR
97208-3777
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-5050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61134895
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2704298579
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202212732NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: