Basic Information
| Provider Information | |||||||||
| NPI: | 1215103882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLEN | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | BREEZE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23343 NW COUNTY ROAD 236 | ||||||||
| Address2: | |||||||||
| City: | HIGH SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326439669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524632374 | ||||||||
| FaxNumber: | 3524634507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326194713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524631100 | ||||||||
| FaxNumber: | 3524634507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9219280 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 309129500 | 05 | FL | MEDICAID | AV943Z | 01 | FL | MEDICARE PTAN | OTHER |