Provider Demographics
NPI:1568060846
Name:PROTHRO, CRYSTALINE JOI (NP-C)
Entity type:Individual
Prefix:
First Name:CRYSTALINE
Middle Name:JOI
Last Name:PROTHRO
Suffix:
Gender:
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 BRYCE MANOR LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6256
Mailing Address - Country:US
Mailing Address - Phone:770-912-9830
Mailing Address - Fax:
Practice Address - Street 1:2782 N COBB PKWY
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3472
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN233492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily