Healthcare Provider Details

I. General information

NPI: 1154898179
Provider Name (Legal Business Name): CRYSTAL B CLARK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S PEARL ST
PAGELAND SC
29728-2261
US

IV. Provider business mailing address

2223 CAMP CREEK RD
LANCASTER SC
29720-8511
US

V. Phone/Fax

Practice location:
  • Phone: 803-288-9495
  • Fax: 989-214-7326
Mailing address:
  • Phone: 704-292-3651
  • Fax: 989-214-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22378
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22378
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number22378
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: