Provider Demographics
NPI:1215353073
Name:VAN DETTE, CRYSTAL DANAE (ARNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DANAE
Last Name:VAN DETTE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919W SWANN AVE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4049
Mailing Address - Country:US
Mailing Address - Phone:813-870-3971
Mailing Address - Fax:
Practice Address - Street 1:2919W SWANN AVE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4049
Practice Address - Country:US
Practice Address - Phone:813-870-3971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9268840363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology