Provider Demographics
NPI:1518156488
Name:VAN WERT, CRYSTAL LYNN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:VAN WERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:23123 OAK VIEW HGTS
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537
Mailing Address - Country:US
Mailing Address - Phone:218-998-3778
Mailing Address - Fax:218-998-3187
Practice Address - Street 1:106 NORTH 4TH AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0653198164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse