Provider Demographics
NPI:1316219272
Name:SUBOTICH, CRYSTAL JOSEPHINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:JOSEPHINE
Last Name:SUBOTICH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22170 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-6007
Mailing Address - Country:US
Mailing Address - Phone:248-372-6800
Mailing Address - Fax:248-355-1402
Practice Address - Street 1:22170 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6007
Practice Address - Country:US
Practice Address - Phone:248-372-6800
Practice Address - Fax:248-355-1402
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704151724163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse