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General NPI Number Information
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NPI Number | 1376333930
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Entity Type | Organization
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Legal Business Name | CRYSTAL HEALTH CARE NURSE PRACTITIONER IN FAMILY HEALTH P.C.
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 11/21/2025
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Provider Practice Location Address
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Address Line | 11410 MERRICK BLVD
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City | JAMAICA
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State | NY
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Zip | 11434-1335
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Country | US
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Telephone | 917-653-0577
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Fax | 516-743-0323
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Provider Business Mailing Address
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Address Line | 1 WINTER LN
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City | AMITYVILLE
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State | NY
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Zip | 11701-1626
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Country | US
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Telephone | 917-653-0577
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Fax | 516-743-0323
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Authorized Official
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Title or Position | CEO
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Name | OMOTUNDE D ADERIN
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Credential | NURSE PRACTITIONER
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Telephone | 917-653-0577
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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