Provider Demographics
NPI:1336163948
Name:VERNON, CRYSTAL (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:VERNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:NOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3799
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-3799
Mailing Address - Country:US
Mailing Address - Phone:931-245-7000
Mailing Address - Fax:931-245-7068
Practice Address - Street 1:490 DUNLOP LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5007
Practice Address - Country:US
Practice Address - Phone:931-245-7000
Practice Address - Fax:931-245-7069
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41346208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010124Medicaid