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General NPI Number Information
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NPI Number | 1154898179
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Entity Type | Individual
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Provider Name | CRYSTAL B CLARK FNP-C
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Gender | Female
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Dates
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Enumeration Date | 10/29/2018
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 211 S PEARL ST
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City | PAGELAND
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State | SC
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Zip | 29728-2261
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Country | US
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Telephone | 803-288-9495
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Fax | 989-214-7326
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Provider Business Mailing Address
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Address Line | 2223 CAMP CREEK RD
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City | LANCASTER
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State | SC
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Zip | 29720-8511
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Country | US
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Telephone | 704-292-3651
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Fax | 989-214-7326
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 22378
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 22378
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 22378
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License Number State | SC
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