Healthcare Provider Details

I. General information

NPI: 1073184396
Provider Name (Legal Business Name): CRYSTAL MARIE KOLLING APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 N US HIGHWAY 701 BYP
TABOR CITY NC
28463-9324
US

IV. Provider business mailing address

PO BOX 187
FAISON NC
28341-0187
US

V. Phone/Fax

Practice location:
  • Phone: 910-653-1901
  • Fax: 910-320-8435
Mailing address:
  • Phone: 910-267-2042
  • Fax: 855-996-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5020044
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5020044
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6578490-4405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26579
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: