Provider Demographics
NPI:1568709129
Name:LARGE, CRYSTAL (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:LARGE
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:PO BOX 3077
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-3077
Mailing Address - Country:US
Mailing Address - Phone:276-328-2961
Mailing Address - Fax:276-328-2965
Practice Address - Street 1:517 W MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-6905
Practice Address - Country:US
Practice Address - Phone:276-328-2961
Practice Address - Fax:276-328-2965
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170577363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily