Provider Demographics
NPI:1700163771
Name:CRULL, JESSICA LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:CRULL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:YANUSZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-801-1000
Mailing Address - Fax:704-896-2961
Practice Address - Street 1:12905 ROSEDALE HILL AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-0328
Practice Address - Country:US
Practice Address - Phone:704-801-1000
Practice Address - Fax:704-896-2861
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005386363L00000X, 363LF0000X
NC207353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006167Medicaid
NC1700163771Medicaid
SCNP2522Medicaid
NCNC3570AMedicare PIN
NC1700163771Medicaid
SCNP2522Medicaid
NC7006167Medicaid
NCNC3570EMedicare PIN
NCNC3570DMedicare PIN
NCNC3570CMedicare PIN