Healthcare Provider Details

I. General information

NPI: 1548405962
Provider Name (Legal Business Name): CRYSTAL GILLIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2008
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 FAIRVIEW ST
CLINTON NC
28328-2399
US

IV. Provider business mailing address

6417 ALLIE COOPER RD
GODWIN NC
28344-8379
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-6011
  • Fax: 910-592-0819
Mailing address:
  • Phone: 910-592-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number170713
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5012411
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: