Provider Demographics
NPI:1073173142
Name:WADE, CRYSTAL ANN (MSN, AG-ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANN
Last Name:WADE
Suffix:
Gender:F
Credentials:MSN, AG-ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 MARSH HAWK LN APT 13102
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3309
Mailing Address - Country:US
Mailing Address - Phone:757-291-3876
Mailing Address - Fax:
Practice Address - Street 1:655 W. EIGHTH ST
Practice Address - Street 2:ACC BUILDING 2ND FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-3220
Practice Address - Country:US
Practice Address - Phone:904-244-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002837363L00000X, 363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily