Provider Demographics
NPI:1609228410
Name:ROBERTS, CRYSTAL D (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:ROBERTS
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 8818
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-8818
Mailing Address - Country:US
Mailing Address - Phone:478-953-1800
Mailing Address - Fax:478-953-1931
Practice Address - Street 1:200 S HOUSTON LAKE RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9006
Practice Address - Country:US
Practice Address - Phone:478-953-1800
Practice Address - Fax:478-953-1931
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN199360363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN199360OtherNURSE PRACTITIONER LICENSE NUMBER