MEDICARE: CRYSTAL JANE HUMPHRIES APRN

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	3011675	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	PDZ000000064864	OTHER	AETNA BETTER HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	9919431	OTHER	AETNA PIN
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000001143675	OTHER	ANTHEM PIN
6	CS1814200203	OTHER	CARESOURCE ID

General Provider Information

NPI Number	:	1962929307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL JANE HUMPHRIES APRN

Provider Business Mailing Address
First Line	:	112 CREEK ROCK CIR
Second Line	:
City	:	NICHOLASVILLE
State	:	KY
Zip	:	40356-8037
Country	:	US
Telephone Number	:	859-948-3697
Fax Number	:	502-863-7542

Provider Business Practice Location Address
First Line	:	1718 ALEXANDRIA DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-3144
Country	:	US
Telephone Number	:	859-276-1015
Fax Number	:	859-277-1015

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

Provider Enumeration Date	:	08/25/2017
Last Update Date	:	05/13/2022

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Directions to “ CRYSTAL JANE HUMPHRIES APRN” Practice Location

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