Provider Demographics
NPI:1508372277
Name:PENNINO, CRYSTAL (NP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:PENNINO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CARLANNA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 GATEWAY CT
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5672
Practice Address - Country:US
Practice Address - Phone:907-228-6558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK22403163W00000X
AK166689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse