Provider Demographics
NPI:1275995607
Name:GILLESPIE, CRYSTAL RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENEE
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FILE 50670
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0670
Mailing Address - Country:US
Mailing Address - Phone:888-227-3312
Mailing Address - Fax:
Practice Address - Street 1:17010 CHATSWORTH ST
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-5844
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA56201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant