Healthcare Provider Details

I. General information

NPI: 1902478365
Provider Name (Legal Business Name): CRYSTAL O'CONNOR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 08/01/2022
Certification Date: 08/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 PETERS CREEK RD STE 110
ROANOKE VA
24019-4060
US

IV. Provider business mailing address

6701 PETERS CREEK RD STE 110
ROANOKE VA
24019-4060
US

V. Phone/Fax

Practice location:
  • Phone: 800-765-7130
  • Fax: 540-438-0023
Mailing address:
  • Phone: 800-765-7130
  • Fax: 885-001-8918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024182120
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: