Provider Demographics
NPI:1720782154
Name:ESTRADA, CRYSTAL ELENA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELENA
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14124 HONORE AVE
Mailing Address - Street 2:
Mailing Address - City:DIXMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1115
Mailing Address - Country:US
Mailing Address - Phone:708-203-1254
Mailing Address - Fax:
Practice Address - Street 1:5174 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804
Practice Address - Country:US
Practice Address - Phone:708-222-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILF03230543363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily