Provider Demographics
NPI:1528637493
Name:LONG, KRYSTAL LASHA (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:LASHA
Last Name:LONG
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:PICKWICK DAM
Mailing Address - State:TN
Mailing Address - Zip Code:38365-0140
Mailing Address - Country:US
Mailing Address - Phone:731-689-4357
Mailing Address - Fax:731-689-1050
Practice Address - Street 1:11268 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:COUNCE
Practice Address - State:TN
Practice Address - Zip Code:38326-3802
Practice Address - Country:US
Practice Address - Phone:731-689-4357
Practice Address - Fax:731-689-1050
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNAPN28080363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily