Provider Demographics
NPI:1609112333
Name:TILLMAN, CRYSTAL LYNNE (DNP, CPNP, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:LYNNE
Last Name:TILLMAN
Suffix:
Gender:F
Credentials:DNP, CPNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1104
Mailing Address - Country:US
Mailing Address - Phone:704-906-1428
Mailing Address - Fax:
Practice Address - Street 1:1055 DRESSER CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7323
Practice Address - Country:US
Practice Address - Phone:919-876-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300186363LP0808X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC300186OtherNURSING AND MEDICAL BOARD PRESCRIBING NUMBER