Provider Demographics
NPI:1952757247
Name:HENDERSON, CRYSTAL LAREE (NP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LAREE
Last Name:HENDERSON
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 1:937 HIGHLAND BLVD
Mailing Address - Street 2:# 5410
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-2400
Mailing Address - Fax:
Practice Address - Street 1:937 HIGHLAND BLVD STE 5410
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6916
Practice Address - Country:US
Practice Address - Phone:406-414-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-05
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT143815363LF0000X
WY28230.1516363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1952757247Medicaid