Healthcare Provider Details

I. General information

NPI: 1629679279
Provider Name (Legal Business Name): CRYSTAL LYNN BAKER DNP, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS CRYSTAL LYNN SANDERS

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SKYLINE DR
RUSSELLVILLE AR
72801-3362
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-7170
  • Fax: 479-968-7607
Mailing address:
  • Phone: 501-852-1363
  • Fax: 501-852-1364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number125821
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number125821
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: