Healthcare Provider Details

I. General information

NPI: 1881019305
Provider Name (Legal Business Name): CRYSTAL L HANCOCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12978 NORTH MAIN STREET
TRENTON GA
30752
US

IV. Provider business mailing address

12978 NORTH MAIN STREET
TRENTON GA
30752
US

V. Phone/Fax

Practice location:
  • Phone: 706-657-4183
  • Fax: 706-657-4270
Mailing address:
  • Phone: 706-657-4183
  • Fax: 706-657-4270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN213708
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: