Provider Demographics
NPI:1679965180
Name:MANDERS, CRYSTAL (RN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MANDERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:GRAPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:519 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3315
Mailing Address - Country:US
Mailing Address - Phone:920-475-8288
Mailing Address - Fax:
Practice Address - Street 1:519 GROVE ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3315
Practice Address - Country:US
Practice Address - Phone:920-475-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-21
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI200957163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse