Provider Demographics
NPI:1962929307
Name:HUMPHRIES, CRYSTAL JANE (APRN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JANE
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CREEK ROCK CIR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8037
Mailing Address - Country:US
Mailing Address - Phone:859-948-3697
Mailing Address - Fax:502-863-7542
Practice Address - Street 1:1718 ALEXANDRIA DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3144
Practice Address - Country:US
Practice Address - Phone:859-276-1015
Practice Address - Fax:859-277-1015
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011675363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PDZ000000064864OtherAETNA BETTER HEALTH
IN300009625Medicaid
9919431OtherAETNA PIN
KY7100519400Medicaid
000001143675OtherANTHEM PIN
CS1814200203OtherCARESOURCE ID