Provider Demographics
NPI:1154859007
Name:HARRIS, CHRYSTAL RACQUEL (AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:RACQUEL
Last Name:HARRIS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 FOREST SIDE DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-2329
Mailing Address - Country:US
Mailing Address - Phone:810-874-5200
Mailing Address - Fax:
Practice Address - Street 1:2 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5903
Practice Address - Country:US
Practice Address - Phone:810-238-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704297913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine