Provider Demographics
NPI:1023821196
Name:ROSE, CRYSTAL LEIGH (FNP-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEIGH
Last Name:ROSE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6382 S APEX AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1060
Mailing Address - Country:US
Mailing Address - Phone:208-901-6094
Mailing Address - Fax:
Practice Address - Street 1:425 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6035
Practice Address - Country:US
Practice Address - Phone:208-901-6094
Practice Address - Fax:208-343-5301
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2671947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily