Provider Demographics
NPI:1649753369
Name:WALLIN, CRYSTAL G (RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:G
Last Name:WALLIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU CHIEN
Mailing Address - State:WI
Mailing Address - Zip Code:53821-2015
Mailing Address - Country:US
Mailing Address - Phone:608-606-0869
Mailing Address - Fax:
Practice Address - Street 1:70 WILLIAM AVE
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU CHIEN
Practice Address - State:WI
Practice Address - Zip Code:53821-8075
Practice Address - Country:US
Practice Address - Phone:608-606-0869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI242938-30163WH0200X
WI242938163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health