Healthcare Provider Details

I. General information

NPI: 1114797883
Provider Name (Legal Business Name): CRYSTAL LEE DNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

685 SHELBY TRL STE 104
CONWAY AR
72034-7169
US

IV. Provider business mailing address

701 SOUTH ST STE 100
MOUNTAIN HOME AR
72653-4452
US

V. Phone/Fax

Practice location:
  • Phone: 501-255-8100
  • Fax:
Mailing address:
  • Phone: 501-808-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number229585
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR105940
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: