MEDICARE: CRYSTAL DOMINIQUE RAY PARKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	5023226	NC
2	2084P0804X	Child & Adolescent Psychiatry Physician	5023226	NC
3	2084P0805X	Geriatric Psychiatry Physician	5023226	NC
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	5023226	NC

General Provider Information

NPI Number	:	1982578647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL DOMINIQUE RAY PARKER

Provider Business Mailing Address
First Line	:	2920 FORESTVILLE RD STE 100-1082
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8774
Country	:	US
Telephone Number	:	919-986-9785
Fax Number	:

Provider Business Practice Location Address
First Line	:	2920 FORESTVILLE RD STE 100-1082
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8774
Country	:	US
Telephone Number	:	984-325-6143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2025
Last Update Date	:	10/03/2025

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