Provider Demographics
NPI:1114797883
Name:LEE, CRYSTAL (DNP, PMHNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 WEAVER CIR
Mailing Address - Street 2:
Mailing Address - City:VILONIA
Mailing Address - State:AR
Mailing Address - Zip Code:72173-9014
Mailing Address - Country:US
Mailing Address - Phone:501-574-2244
Mailing Address - Fax:
Practice Address - Street 1:685 SHELBY TRL STE 104
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7169
Practice Address - Country:US
Practice Address - Phone:501-255-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR105940163WP0808X
AR229585363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health