Provider Demographics
NPI:1467826693
Name:SOUZA, CRYSTAL LISE (FNP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LISE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LISE
Other - Last Name:TAVERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ STE 400
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4760
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:300 CENTERVILLE RD STE 110
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886
Practice Address - Country:US
Practice Address - Phone:401-615-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-27
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10730363LF0000X
RIAPRN00778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1467826693Medicaid