Provider Demographics
NPI:1760786479
Name:WILSON, CRYSTAL ROSE (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ROSE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 N SHILOH ROAD
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834
Mailing Address - Country:US
Mailing Address - Phone:662-486-2710
Mailing Address - Fax:
Practice Address - Street 1:3124 N SHILOH ROAD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834
Practice Address - Country:US
Practice Address - Phone:662-486-2710
Practice Address - Fax:662-762-0690
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05529352Medicaid