Provider Demographics
NPI:1548405962
Name:GILLIS, CRYSTAL (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:GILLIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 ALLIE COOPER RD
Mailing Address - Street 2:
Mailing Address - City:GODWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28344-8379
Mailing Address - Country:US
Mailing Address - Phone:910-891-8369
Mailing Address - Fax:
Practice Address - Street 1:403 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2399
Practice Address - Country:US
Practice Address - Phone:105-929-6011
Practice Address - Fax:910-592-0819
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012411363LF0000X
NC170713163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH1000XNursing Service ProvidersRegistered NurseHospice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC170713OtherNORTH CAROLINA BOARD OF NURSING
NC5012411OtherFAMILY NURSE PRACTITIONER