Provider Demographics
NPI:1124567581
Name:MANN-ELLIS, CRYSTAL (NP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MANN-ELLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 SANTA ROSA RD RM 114
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5109
Mailing Address - Country:US
Mailing Address - Phone:804-210-3101
Mailing Address - Fax:
Practice Address - Street 1:1504 SANTA ROSA RD RM 114
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23229-5109
Practice Address - Country:US
Practice Address - Phone:804-210-3103
Practice Address - Fax:804-210-3104
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-18
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily