Provider Demographics
NPI:1033593918
Name:DILLETT, CRYSTAL J (NP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:DILLETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:J
Other - Last Name:PLATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:146 E GENEVA SQ
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-9694
Mailing Address - Country:US
Mailing Address - Phone:262-939-5459
Mailing Address - Fax:
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9694
Practice Address - Country:US
Practice Address - Phone:262-939-5459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6443363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100047118Medicaid