Provider Demographics
NPI:1124798392
Name:BRASSFIELD, CRYSTAL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BRASSFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 WILLOW BEND DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-6920
Mailing Address - Country:US
Mailing Address - Phone:601-934-8474
Mailing Address - Fax:
Practice Address - Street 1:2701 DAVIS ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5708
Practice Address - Country:US
Practice Address - Phone:601-693-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904836363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care