Provider Demographics
NPI:1942567763
Name:CLARK, CRYSTAL Y (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:Y
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 RURAL ACRES DR.
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801
Mailing Address - Country:US
Mailing Address - Phone:304-253-2628
Mailing Address - Fax:
Practice Address - Street 1:200 RALEIGH AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5961
Practice Address - Country:US
Practice Address - Phone:304-252-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV63168363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily