Healthcare Provider Details

I. General information

NPI: 1811509599
Provider Name (Legal Business Name): CRYSTAL DAWN LOWDER-TIBBS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2020
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1054 BOONES MILL RD
BOONES MILL VA
24065-4318
US

IV. Provider business mailing address

1054 BOONES MILL RD
BOONES MILL VA
24065-4318
US

V. Phone/Fax

Practice location:
  • Phone: 276-724-0967
  • Fax:
Mailing address:
  • Phone: 276-724-0967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179874
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0024179874
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: