Provider Demographics
NPI:1568060846
Name:PROTHRO, CRYSTALINE JOI (NP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTALINE
Middle Name:JOI
Last Name:PROTHRO
Suffix:
Gender:F
Credentials:NP-C
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 813
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-0813
Mailing Address - Country:US
Mailing Address - Phone:770-912-9830
Mailing Address - Fax:
Practice Address - Street 1:1305 HEMBREE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-3810
Practice Address - Country:US
Practice Address - Phone:470-485-6342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN233492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily