Provider Demographics
NPI:1033961180
Name:LA ROSE, CRYSTAL LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:LA ROSE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:CLYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4040 TROTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-8007
Mailing Address - Country:US
Mailing Address - Phone:928-302-0622
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 860
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941-0860
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ223670367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife