MEDICARE: CRYSTAL MAGGARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	28157248A	IN
2	363L00000X	Nurse Practitioner	71006403A	IN

General Provider Information

NPI Number	:	1356792972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL MAGGARD

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8175 W US HIGHWAY 20
Second Line	:
City	:	SHIPSHEWANA
State	:	IN
Zip	:	46565-9169
Country	:	US
Telephone Number	:	260-768-7432
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2016
Last Update Date	:	10/08/2022

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Directions to “ CRYSTAL MAGGARD ” Practice Location

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