Provider Demographics
NPI:1386273753
Name:MOORE, CRYSTAL WADE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:WADE
Last Name:MOORE
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 1:448 W BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3016
Mailing Address - Country:US
Mailing Address - Phone:762-204-6444
Mailing Address - Fax:
Practice Address - Street 1:448 W BELMONT DR
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3016
Practice Address - Country:US
Practice Address - Phone:762-204-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA222790363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily