Provider Demographics
NPI:1396957932
Name:KRUSHALL, MYRTLE JEAN (NP)
Entity type:Individual
Prefix:
First Name:MYRTLE
Middle Name:JEAN
Last Name:KRUSHALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3838 SHERMAN DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-4001
Mailing Address - Country:US
Mailing Address - Phone:951-343-1700
Mailing Address - Fax:951-343-1777
Practice Address - Street 1:3838 SHERMAN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-4001
Practice Address - Country:US
Practice Address - Phone:951-343-1700
Practice Address - Fax:951-343-1777
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1882363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA221779OtherRN
CA1882OtherNP