Provider Demographics
NPI:1457590507
Name:BATES, CRYSTAL AMMONS (FNP-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:AMMONS
Last Name:BATES
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-2067
Practice Address - Street 1:105 HANES SQUARE CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5514
Practice Address - Country:US
Practice Address - Phone:336-441-5569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011298363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC363LF0000XMedicaid