MEDICARE: CRYSTAL NICOLE CHANCELLOR APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	212540	AR

General Provider Information

NPI Number	:	1013515857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL NICOLE CHANCELLOR APRN

Provider Business Mailing Address
First Line	:	212 MOUNTAIN VIEW RD
Second Line	:
City	:	GLENWOOD
State	:	AR
Zip	:	71943-9183
Country	:	US
Telephone Number	:	870-828-1022
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 S BOWMAN RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-4136
Country	:	US
Telephone Number	:	870-828-1022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	11/02/2023

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