Provider Demographics
NPI:1356792972
Name:MAGGARD, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MAGGARD
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8175 W US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-9169
Practice Address - Country:US
Practice Address - Phone:260-768-7432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2022-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28157248A363LF0000X
IN71006403A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily