Provider Demographics
NPI:1194122671
Name:FAGERSTROM, CRYSTAL LYNN
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:FAGERSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:NAGARUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 PUNGUK STREET
Mailing Address - Street 2:
Mailing Address - City:GOLOVIN
Mailing Address - State:AK
Mailing Address - Zip Code:99762
Mailing Address - Country:US
Mailing Address - Phone:907-779-3311
Mailing Address - Fax:907-779-3312
Practice Address - Street 1:39 PUNGUK STREET
Practice Address - Street 2:
Practice Address - City:GOLOVIN
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-779-3311
Practice Address - Fax:907-779-3312
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA III-COtherCHA III-C