Provider Demographics
NPI:1457729139
Name:MENICK, CRYSTAL (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MENICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3604 WATERWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ISLE OF PALMS
Mailing Address - State:SC
Mailing Address - Zip Code:29451-2552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 NASSAU ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5513
Practice Address - Country:US
Practice Address - Phone:843-722-4112
Practice Address - Fax:843-577-8960
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC241914363L00000X
SC19693363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner