Provider Demographics
NPI:1609521152
Name:HENNINGS, CRYSTAL EVELYN (DPT)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:EVELYN
Last Name:HENNINGS
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5611
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-0611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2203 OAK ST
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-0137
Practice Address - Country:US
Practice Address - Phone:907-224-2800
Practice Address - Fax:907-224-3798
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK185408208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1729901Medicaid