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General NPI Number Information
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NPI Number | 1538775390
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Entity Type | Individual
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Provider Name | CRYSTAL MARIE MCNALLY
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Gender | Female
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Dates
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Enumeration Date | 09/17/2020
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 5089 SE 1 1/2 AVE
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City | NEW PLYMOUTH
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State | ID
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Zip | 83655-5254
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Country | US
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Telephone | 986-207-1720
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Fax | 866-531-4582
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Provider Business Mailing Address
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Address Line | 5089 SE 1 1/2 AVE
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City | NEW PLYMOUTH
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State | ID
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Zip | 83655-5254
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Country | US
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Telephone | 986-207-1720
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Fax | 866-531-4582
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 55712
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 202008407NP-PP
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License Number State | OR
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