Provider Demographics
NPI:1043582901
Name:CLARK, CRYSTAL L (APRN, CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN, CRNA
Other - Prefix:MS
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:STEELE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CRNA
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:N202
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5956
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:N202
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT103183367500000X
OHCOA.14396-NA367500000X
OHRN.347094-COA1163W00000X
KY1108974367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse