Provider Demographics
NPI:1225635212
Name:BAILEY, CRYSTAL KEYONNICA
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:KEYONNICA
Last Name:BAILEY
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 1:44 DARBYS CROSSING DR STE 110A
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-6048
Mailing Address - Country:US
Mailing Address - Phone:770-575-0022
Mailing Address - Fax:
Practice Address - Street 1:44 DARBYS CROSSING DR STE 110A
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-6048
Practice Address - Country:US
Practice Address - Phone:770-575-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-03
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN240322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily