Provider Demographics
NPI:1548576937
Name:DALE, CRYSTAL (APRN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:DALE
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 1:740 S LIMESTOME E101
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:859-323-8082
Mailing Address - Fax:859-323-2441
Practice Address - Street 1:740 S LIMESTONE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0284
Practice Address - Country:US
Practice Address - Phone:859-323-8082
Practice Address - Fax:859-323-2441
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100138670Medicaid