Provider Demographics
NPI:1801047469
Name:NEVINS, CRYSTAL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:NEVINS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 NYDIA CT
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-9500
Mailing Address - Country:US
Mailing Address - Phone:631-820-2100
Mailing Address - Fax:
Practice Address - Street 1:7 NYDIA CT
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980-9500
Practice Address - Country:US
Practice Address - Phone:631-820-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY602969-1Medicaid