=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770252173
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL LEE KOMP CNM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2021
-----------------------------------------------------
Last Update Date | 10/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N8150 AMUNDSON COULEE RD
-----------------------------------------------------
City | HOLMEN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-343-8744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N8150 AMUNDSON COULEE RD
-----------------------------------------------------
City | HOLMEN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-343-8744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | CNM07255
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 483
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367A00000X
-----------------------------------------------------
Taxonomy Name | Advanced Practice Midwife
-----------------------------------------------------
License Number | 149023-32
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------