Provider Demographics
NPI:1285793547
Name:CHRYSTAL, LARRAINE D (ARNP)
Entity type:Individual
Prefix:
First Name:LARRAINE
Middle Name:D
Last Name:CHRYSTAL
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 1:299 GREENDALE RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:VT
Mailing Address - Zip Code:05730-9724
Mailing Address - Country:US
Mailing Address - Phone:802-236-1772
Mailing Address - Fax:
Practice Address - Street 1:160 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4560
Practice Address - Country:US
Practice Address - Phone:802-775-7111
Practice Address - Fax:802-747-6260
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0013910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP3249Medicaid
P31184Medicare UPIN
VTNP3249Medicare ID - Type Unspecified