Provider Demographics
NPI:1104648732
Name:CHRYSALIS PSYCHIATRY
Entity type:Organization
Organization Name:CHRYSALIS PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:KOOMEN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:415-847-4643
Mailing Address - Street 1:PO BOX 1093
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-1093
Mailing Address - Country:US
Mailing Address - Phone:206-279-4547
Mailing Address - Fax:
Practice Address - Street 1:1001 WATER ST # 1009
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6705
Practice Address - Country:US
Practice Address - Phone:206-279-4547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty