Provider Demographics
NPI:1457738387
Name:BOHANNON, CRYSTAL NICOLE (APRN-NP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:BOHANNON
Suffix:
Gender:F
Credentials:APRN-NP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:NICOLE
Other - Last Name:BRISTOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN-NP
Mailing Address - Street 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-231-7680
Mailing Address - Fax:502-231-8149
Practice Address - Street 1:8111 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-3441
Practice Address - Country:US
Practice Address - Phone:502-231-7680
Practice Address - Fax:502-231-8149
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100382320 (KOHMG)Medicaid
KYK196660 (KOHMG)Medicare PIN
KY7100382320 (KOHMG)Medicaid