Provider Demographics
NPI:1770735078
Name:MOORE, CRYSTAL LYNN (FNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:MOORE
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 1:1 UNIVERSITY RD
Mailing Address - Street 2:STUDENT HEALTH SERVICES
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-8699
Mailing Address - Country:US
Mailing Address - Phone:910-521-6219
Mailing Address - Fax:910-521-6549
Practice Address - Street 1:1 UNIVERSITY RD
Practice Address - Street 2:STUDENT HEALTH SERVICES
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-8699
Practice Address - Country:US
Practice Address - Phone:910-521-6219
Practice Address - Fax:910-521-6549
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005089Medicaid
NC7005089Medicaid