Provider Demographics
NPI:1417224239
Name:BRANHAM, CRYSTAL L (APRN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:BRANHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-5810
Mailing Address - Country:US
Mailing Address - Phone:606-788-9259
Mailing Address - Fax:606-788-9307
Practice Address - Street 1:112 EAST STREET
Practice Address - Street 2:
Practice Address - City:ELKHORN CITY
Practice Address - State:KY
Practice Address - Zip Code:41522
Practice Address - Country:US
Practice Address - Phone:606-788-9259
Practice Address - Fax:606-788-9307
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-22
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007228363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3007228OtherKENTUCKY APRN LICENSURE
KY7100196230Medicaid
KY2011013543OtherAMERICAN NURSES /FAMILY NURSE PRACTITIONER
KY3007228OtherKENTUCKY APRN LICENSURE