Healthcare Provider Details

I. General information

NPI: 1295168961
Provider Name (Legal Business Name): CRYSTAL ROSE BUCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MARKETPLACE DR SUITE 102
ROCKY MOUNT VA
24151-6516
US

IV. Provider business mailing address

550 N FRANKLIN ST
CHRISTIANSBURG VA
24073-1916
US

V. Phone/Fax

Practice location:
  • Phone: 540-483-3678
  • Fax: 540-483-3820
Mailing address:
  • Phone: 434-390-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171113
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: