Provider Demographics
NPI:1194226837
Name:BELCOURT, CRYSTAL GAIL (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:BELCOURT
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2025
Mailing Address - Country:US
Mailing Address - Phone:208-871-9579
Mailing Address - Fax:
Practice Address - Street 1:1620 S KIMBALL AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4547
Practice Address - Country:US
Practice Address - Phone:208-505-2950
Practice Address - Fax:208-505-2955
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58461363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics