Provider Demographics
NPI:1982915237
Name:ELLISON, CRYSTAL (NP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ELLISON
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-579-3203
Mailing Address - Fax:
Practice Address - Street 1:15021 W BELL RD STE 125
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3916
Practice Address - Country:US
Practice Address - Phone:623-476-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ272968363LF0000X
AZRN195571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ123887Medicaid