Provider Demographics
NPI:1083116719
Name:DAVERN, CRYSTAL NICHOLE (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICHOLE
Last Name:DAVERN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:NICHOLE
Other - Last Name:FROHNHEISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:8 DEEPWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4244
Mailing Address - Country:US
Mailing Address - Phone:716-715-7004
Mailing Address - Fax:
Practice Address - Street 1:8 DEEPWOOD CT
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4244
Practice Address - Country:US
Practice Address - Phone:716-715-7004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3206371164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse