Basic Information
| Provider Information | |||||||||
| NPI: | 1659839579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AULT | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 S FISKE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329554306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214343430 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 ELDRON BLVD SE | ||||||||
| Address2: | |||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214343430 | ||||||||
| FaxNumber: | 3214343432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2019 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11001227 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | LW950 | 01 | FL | MEDICARE | OTHER |