Provider Demographics
NPI:1457195380
Name:CLARK, CRYSTAL DAWN (FNP-BC)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DAWN
Last Name:CLARK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:TN
Mailing Address - Zip Code:38474-1103
Mailing Address - Country:US
Mailing Address - Phone:931-446-5778
Mailing Address - Fax:
Practice Address - Street 1:1605 NASHVILLE HWY STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-2132
Practice Address - Country:US
Practice Address - Phone:931-540-4210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36529208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice