Provider Demographics
NPI:1659792398
Name:KUPSICK, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:KUPSICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:QUIGLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:317 30TH ST APT 310D
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7655
Mailing Address - Country:US
Mailing Address - Phone:541-556-7829
Mailing Address - Fax:
Practice Address - Street 1:2073 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3413
Practice Address - Country:US
Practice Address - Phone:541-687-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-24
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130520LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse