Provider Demographics
NPI:1013515857
Name:CHANCELLOR, CRYSTAL NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:NICOLE
Last Name:CHANCELLOR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:71943-9183
Mailing Address - Country:US
Mailing Address - Phone:870-828-1022
Mailing Address - Fax:
Practice Address - Street 1:2200 S BOWMAN RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4136
Practice Address - Country:US
Practice Address - Phone:870-828-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR212540363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology