Provider Demographics
NPI:1871064436
Name:PENA, CRYSTAL HUSTAD (APRN, NP-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:HUSTAD
Last Name:PENA
Suffix:
Gender:F
Credentials:APRN, NP-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:NICOLE
Other - Last Name:HUSTAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 LONG BEACH BLVD UNIT 122
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3186
Mailing Address - Country:US
Mailing Address - Phone:714-316-6530
Mailing Address - Fax:
Practice Address - Street 1:3440 LOMITA BLVD STE 240
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4871
Practice Address - Country:US
Practice Address - Phone:310-539-5060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty