Provider Demographics
NPI:1699152025
Name:KELLY, CRYSTAL (RN, FNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 DRAPER DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-2541
Mailing Address - Country:US
Mailing Address - Phone:704-682-3194
Mailing Address - Fax:
Practice Address - Street 1:903 NORTHEAST DR
Practice Address - Street 2:SUITE 301
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-7416
Practice Address - Country:US
Practice Address - Phone:704-894-9309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty