Provider Demographics
NPI:1770250516
Name:GILLISPIE, CRYSTAL LEIGH (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEIGH
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LEIGH
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 SHAW BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:FOSTER
Mailing Address - State:WV
Mailing Address - Zip Code:25081-6270
Mailing Address - Country:US
Mailing Address - Phone:304-545-0950
Mailing Address - Fax:
Practice Address - Street 1:701 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1669
Practice Address - Country:US
Practice Address - Phone:304-369-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-29
Last Update Date:2021-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV110020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily