Healthcare Provider Details

I. General information

NPI: 1811795073
Provider Name (Legal Business Name): CRYSTAL LYNN PEMBERTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL LYNN PEMBERTON FNP-C

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 RTE 35 STE 5
WALL NJ
07719-3530
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD BLDG 2, STE 220
RED BANK NJ
07701-5688
US

V. Phone/Fax

Practice location:
  • Phone: 732-974-8404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15288400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: