=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225399264
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTAL PLUMMER PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2012
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 DEER PARK AVE
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-358-0848
-----------------------------------------------------
Fax | 631-669-8532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 DEER PARK AVE
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-358-0848
-----------------------------------------------------
Fax | 516-715-3782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 630216
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 402475
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------