MEDICARE: MS. CRYSTAL SMITH FNP-C

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	209015014	IL

General Provider Information

NPI Number	:	1518400308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CRYSTAL SMITH FNP-C

Provider Business Mailing Address
First Line	:	1100 W CERMAK RD
Second Line	:	STE. C-119
City	:	CHICAGO
State	:	IL
Zip	:	60608-4500
Country	:	US
Telephone Number	:	312-243-2223
Fax Number	:	312-243-8450

Provider Business Practice Location Address
First Line	:	1100 W CERMAK RD
Second Line	:	STE. C-119
City	:	CHICAGO
State	:	IL
Zip	:	60608-4500
Country	:	US
Telephone Number	:	312-243-2223
Fax Number	:	312-243-8450

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

Provider Enumeration Date	:	11/28/2016
Last Update Date	:	11/28/2016

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