Provider Demographics
NPI:1124486089
Name:CISZEK, CRYSTAL A (FNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:CISZEK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:A
Other - Last Name:CISZEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:463688 STATE ROAD 200, STE 1
Mailing Address - Street 2:#364
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-0304
Mailing Address - Country:US
Mailing Address - Phone:478-290-0677
Mailing Address - Fax:
Practice Address - Street 1:10752 DEERWOOD PARK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4846
Practice Address - Country:US
Practice Address - Phone:478-290-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN209456363LF0000X
FL11020853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily