Provider Demographics
NPI:1154898179
Name:CLARK, CRYSTAL B (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:B
Last Name:CLARK
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 1:2223 CAMP CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-8511
Mailing Address - Country:US
Mailing Address - Phone:803-577-6026
Mailing Address - Fax:989-214-7326
Practice Address - Street 1:885 GOLD HILL RD # 1003
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-7946
Practice Address - Country:US
Practice Address - Phone:803-288-9495
Practice Address - Fax:989-214-7326
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22378207Q00000X, 363L00000X, 363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5853Medicaid
SC22378OtherAPRN LICENSURE
SC5422378OtherCONTROLLED SUBSTANCE LICENSURE
SCXC5081067OtherX WAIVER
SC5422378OtherCONTROLLED SUBSTANCE LICENSURE