Healthcare Provider Details

I. General information

NPI: 1992015374
Provider Name (Legal Business Name): CRYSTAL KROHN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

PO BOX 40908
FAYETTEVILLE NC
28309-0908
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-5132
  • Fax: 910-321-6236
Mailing address:
  • Phone: 910-615-6448
  • Fax: 910-615-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number206696
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: