Provider Demographics
NPI:1427650464
Name:REIDER, CRISTAL (APRN, CNP)
Entity type:Individual
Prefix:
First Name:CRISTAL
Middle Name:
Last Name:REIDER
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:CRISTAL
Other - Middle Name:
Other - Last Name:DEL REAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21202 OWENS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2038
Mailing Address - Country:US
Mailing Address - Phone:779-334-0030
Mailing Address - Fax:779-334-0031
Practice Address - Street 1:21202 OWENS RD STE 101
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-2038
Practice Address - Country:US
Practice Address - Phone:779-334-0030
Practice Address - Fax:779-334-0031
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28220363A163W00000X
IN71010694A363LF0000X
IL209022335363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300098489Medicaid