Provider Demographics
NPI:1780176396
Name:LEOFFLER, CRYSTAL MARIE (FNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MARIE
Last Name:LEOFFLER
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 70157
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0021
Mailing Address - Country:US
Mailing Address - Phone:843-516-2024
Mailing Address - Fax:843-796-1319
Practice Address - Street 1:9021 BELLA VERDE CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-5110
Practice Address - Country:US
Practice Address - Phone:843-516-2024
Practice Address - Fax:843-796-1319
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21877363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5685Medicaid