Provider Demographics
NPI:1700882131
Name:HUMPHRIES, CRYSTAL E (FNP)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:E
Last Name:HUMPHRIES
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-7050
Practice Address - Fax:864-560-0800
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC73007363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00729159OtherRAILROAD MEDICARE
NC7004423Medicaid
SCQ318733365OtherMEDICARE PIN
SCQ318734746OtherMEDICARE PIN
SCNP0021Medicaid
SCNP0021Medicaid
SCQ318734746Medicare PIN
SC6499Medicare PIN
SCP00729159OtherRAILROAD MEDICARE