Provider Demographics
NPI:1437870680
Name:WITTROCK, CRYSTAL A (NP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:WITTROCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:A
Other - Last Name:WHITEAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-649-3780
Mailing Address - Fax:414-649-3794
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 507
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3660
Practice Address - Country:US
Practice Address - Phone:414-649-3780
Practice Address - Fax:414-649-3794
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI241942363L00000X
WI13139363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100223381Medicaid