Provider Demographics
NPI:1154897379
Name:BLACK, CRYSTAL SUE (FNP-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:SUE
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5940 CROSSLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6986
Mailing Address - Country:US
Mailing Address - Phone:254-666-2999
Mailing Address - Fax:254-666-6000
Practice Address - Street 1:625 W CENTRAL TEXAS EXPY
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1600
Practice Address - Country:US
Practice Address - Phone:254-690-0618
Practice Address - Fax:254-690-0462
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138623363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner