Provider Demographics
NPI:1295031169
Name:CARMACK, CRYSTELLE LEEELLEN (CRNP)
Entity Type:Individual
Prefix:
First Name:CRYSTELLE
Middle Name:LEEELLEN
Last Name:CARMACK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:888-973-8821
Practice Address - Street 1:1 PERIMETER PARK S STE 100N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35243-3248
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4444363LF0000X
TX1104925363LF0000X
SC27084363LF0000X
TN31680363LF0000X
IL209027339363LF0000X
OHAPRN.CNP.0034762363LF0000X
FLAPRN11022060363LF0000X
AL1-109160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I501759OtherMEDICARE
AL1295031169Medicaid