Provider Demographics
NPI:1457540189
Name:BIRDSONG, CRYSTAL ANN (NP)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:ANN
Last Name:BIRDSONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:BIRDSONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1200
Mailing Address - Country:US
Mailing Address - Phone:800-640-3451
Mailing Address - Fax:
Practice Address - Street 1:11417 124TH AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-4677
Practice Address - Country:US
Practice Address - Phone:800-640-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10027979363L00000X
WAAP61577387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX582318Medicare UPIN