Provider Demographics
NPI:1972068757
Name:MARTINEZ, CRYSTAL (NP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 DALLAS HIGH SHOALS HWY UNIT 935
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-1369
Mailing Address - Country:US
Mailing Address - Phone:803-470-5358
Mailing Address - Fax:
Practice Address - Street 1:3151 DALLAS HIGH SHOALS HWY UNIT 935
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1369
Practice Address - Country:US
Practice Address - Phone:803-470-5358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC289876363LF0000X
NC5011600363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF0290156Medicaid