Provider Demographics
NPI:1649813577
Name:BRYAN, CRYSTALYN LOU (NP-C)
Entity type:Individual
Prefix:
First Name:CRYSTALYN
Middle Name:LOU
Last Name:BRYAN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:
Practice Address - Street 1:700 CALDWELL BLVD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-1707
Practice Address - Country:US
Practice Address - Phone:208-466-6567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily