Provider Demographics
NPI:1164882320
Name:WILLIS, CRYSTAL L (MSN, RN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2700 NEWBERRY HWY
Mailing Address - Street 2:
Mailing Address - City:SALUDA
Mailing Address - State:SC
Mailing Address - Zip Code:29138-7395
Mailing Address - Country:US
Mailing Address - Phone:864-344-8600
Mailing Address - Fax:
Practice Address - Street 1:2000 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1002
Practice Address - Country:US
Practice Address - Phone:803-576-2768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC212293163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse