Provider Demographics
NPI:1104522853
Name:RUBY, CRYSTAL ANNE (APRN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANNE
Last Name:RUBY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 N HALE ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-9231
Mailing Address - Country:US
Mailing Address - Phone:435-830-1758
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10826853-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care