Provider Demographics
NPI:1013390350
Name:BERRY, CRYSTAL
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:611 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3627
Mailing Address - Country:US
Mailing Address - Phone:678-729-7973
Mailing Address - Fax:
Practice Address - Street 1:611 BROWN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3627
Practice Address - Country:US
Practice Address - Phone:678-729-7973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN205005363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA84-1481182OtherALL INSURERS