Provider Demographics
NPI:1881822831
Name:O'CONNELL, CRYSTAL LYNN (NP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:
Practice Address - Street 1:300 HANOVER ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-5444
Practice Address - Country:US
Practice Address - Phone:508-973-8611
Practice Address - Fax:508-973-8615
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2260144363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110134143AMedicaid