Provider Demographics
NPI:1891341269
Name:MERIDIETH, KRYSTI DARLENE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTI
Middle Name:DARLENE
Last Name:MERIDIETH
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:KRYSTI
Other - Middle Name:DARLENE
Other - Last Name:BYRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:177 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-7328
Mailing Address - Country:US
Mailing Address - Phone:910-835-6733
Mailing Address - Fax:
Practice Address - Street 1:2587 RAVENHILL DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5451
Practice Address - Country:US
Practice Address - Phone:910-323-1543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant