Provider Demographics
NPI:1467628503
Name:RHODES-WALLS, CHRYSTAL ELAINE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHRYSTAL
Middle Name:ELAINE
Last Name:RHODES-WALLS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CHRYSTAL
Other - Middle Name:ELAINE
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:3009 CHURCH ST STE B
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5983
Mailing Address - Country:US
Mailing Address - Phone:800-932-2738
Mailing Address - Fax:888-847-9306
Practice Address - Street 1:3009 CHURCH ST STE B
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5983
Practice Address - Country:US
Practice Address - Phone:800-932-2738
Practice Address - Fax:888-847-9306
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27369363L00000X
VA0024169391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467628503Medicaid
VAVVB914AMedicare PIN
VAP01277696Medicare PIN