Healthcare Provider Details

I. General information

NPI: 1033645726
Provider Name (Legal Business Name): CRYSTAL DAWN LEBOEUF PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL DAWN GAGNON

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 MAIN ST
SAINT JOHNSBURY VT
05819-2646
US

IV. Provider business mailing address

PO BOX 65
SAINT JOHNSBURY VT
05819-0065
US

V. Phone/Fax

Practice location:
  • Phone: 802-255-8788
  • Fax: 802-200-0493
Mailing address:
  • Phone: 802-255-8788
  • Fax: 802-200-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0135005
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0122541
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number073848-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: