MEDICARE: MRS. CRYSTAL ANN WADE MSN, AG-ACNP-BC

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	363L00000X	Nurse Practitioner	11002837	FL
2	363LF0000X	Family Nurse Practitioner	11002837	FL
3	363LA2200X	Adult Health Nurse Practitioner	11002837	FL

General Provider Information

NPI Number	:	1073173142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CRYSTAL ANN WADE MSN, AG-ACNP-BC

Provider Business Mailing Address
First Line	:	2285 MARSH HAWK LN APT 13102
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-3309
Country	:	US
Telephone Number	:	757-291-3876
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 W. EIGHTH ST
Second Line	:	ACC BUILDING 2ND FLOOR
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3220
Country	:	US
Telephone Number	:	904-244-1010
Fax Number	:

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

Provider Enumeration Date	:	06/19/2019
Last Update Date	:	08/02/2022

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