MEDICARE: CRYSTAL NICOLE BOHANNON APRN-NP

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	363L00000X	Nurse Practitioner	3009368	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457738387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL NICOLE BOHANNON APRN-NP

Provider Business Mailing Address
First Line	:	100 E LIBERTY ST
Second Line	:	SUITE 800
City	:	LOUISVILLE
State	:	KY
Zip	:	40202-1434
Country	:	US
Telephone Number	:	502-231-7680
Fax Number	:	502-231-8149

Provider Business Practice Location Address
First Line	:	8111 BARDSTOWN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-3441
Country	:	US
Telephone Number	:	502-231-7680
Fax Number	:	502-231-8149

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

Provider Enumeration Date	:	04/29/2015
Last Update Date	:	06/10/2020

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