Provider Demographics
NPI:1528780392
Name:DAVIS, CRYSTAL MONIQUE (PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:MONIQUE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 W LINCOLN HWY STE A
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-9491
Mailing Address - Country:US
Mailing Address - Phone:708-918-4488
Mailing Address - Fax:217-910-0598
Practice Address - Street 1:7777 W LINCOLN HWY STE A
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-9491
Practice Address - Country:US
Practice Address - Phone:708-918-4488
Practice Address - Fax:214-910-0598
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025953363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty