Provider Demographics
NPI:1063076313
Name:CANUTO, CRYSTELLE WIONA (NP-C)
Entity type:Individual
Prefix:
First Name:CRYSTELLE
Middle Name:WIONA
Last Name:CANUTO
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CRYSTELLE
Other - Middle Name:WIONA
Other - Last Name:JAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-635-5264
Mailing Address - Fax:
Practice Address - Street 1:1600 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019013218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily