Healthcare Provider Details

I. General information

NPI: 1033906060
Provider Name (Legal Business Name): CRYSTAL BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18877 JEB STUART HWY
STUART VA
24171-5223
US

IV. Provider business mailing address

1132 CARTER MOUNTAIN RD
STUART VA
24171-3769
US

V. Phone/Fax

Practice location:
  • Phone: 276-694-4466
  • Fax:
Mailing address:
  • Phone: 276-952-5514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001194346
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: