Provider Demographics
NPI:1154783470
Name:LIEBLANG, CRYSTAL KAY (CNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:KAY
Last Name:LIEBLANG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:KAY
Other - Last Name:PENNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1222 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3406
Mailing Address - Country:US
Mailing Address - Phone:810-985-9681
Mailing Address - Fax:810-985-5310
Practice Address - Street 1:1222 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3406
Practice Address - Country:US
Practice Address - Phone:810-985-9681
Practice Address - Fax:810-985-5310
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704239482363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner