Healthcare Provider Details

I. General information

NPI: 1366310559
Provider Name (Legal Business Name): CRYSTAL SIBLALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 MEMORIAL MEDICAL PKWY STE 2801
PALM COAST FL
32164-5999
US

IV. Provider business mailing address

770 W GRANADA BLVD STE 101
ORMOND BEACH FL
32174-5179
US

V. Phone/Fax

Practice location:
  • Phone: 386-232-9210
  • Fax: 386-586-1939
Mailing address:
  • Phone: 386-231-4519
  • Fax: 386-368-8927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9120909
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: