Provider Demographics
NPI:1467826693
Name:SOUZA, CRYSTAL LISE (FNP-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LISE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LISE
Other - Last Name:TAVERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:450 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-3207
Mailing Address - Country:US
Mailing Address - Phone:401-767-4100
Mailing Address - Fax:
Practice Address - Street 1:450 CLINTON ST
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3207
Practice Address - Country:US
Practice Address - Phone:401-767-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-27
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10730363LF0000X
RIAPRN00778363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1467826693Medicaid