Provider Demographics
NPI:1629550496
Name:WALLACE, CRYSTAL NICHOLE (NP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICHOLE
Last Name:WALLACE
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 1:3 CARRINGTON CT
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8114
Mailing Address - Country:US
Mailing Address - Phone:601-810-8996
Mailing Address - Fax:
Practice Address - Street 1:50 PARKWAY LN STE B
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3035
Practice Address - Country:US
Practice Address - Phone:601-705-2897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902669363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner