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General NPI Number Information
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NPI Number | 1568709129
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Entity Type | Individual
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Provider Name | CRYSTAL LARGE FNP
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Gender | Female
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Dates
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Enumeration Date | 01/15/2013
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 8207 MEADOW BROOK WAY
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City | WISE
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State | VA
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Zip | 24293
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Country | US
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Telephone | 276-393-9890
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Fax | 276-598-1690
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Provider Business Mailing Address
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Address Line | PO BOX 1688
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City | WISE
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State | VA
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Zip | 24293-1688
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Country | US
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Telephone | 276-393-9890
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Fax | 276-598-1690
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 0024171577
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License Number State | VA
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