Provider Demographics
NPI:1851070817
Name:STEPHENS, CRYSTAL (AG-ACNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 S MANOR CV N
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6618
Mailing Address - Country:US
Mailing Address - Phone:901-786-2041
Mailing Address - Fax:
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-516-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34366363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care