Provider Demographics
NPI:1811980378
Name:SHEAVES, CRYSTAL GAIL (FNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAIL
Last Name:SHEAVES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:GAIL
Other - Last Name:MCKINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:9109 SENECA TRL S
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-1791
Mailing Address - Country:US
Mailing Address - Phone:304-645-1787
Mailing Address - Fax:
Practice Address - Street 1:9109 SENECA TRL S
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-1791
Practice Address - Country:US
Practice Address - Phone:304-645-1787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV53104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7103195000Medicaid
P66260Medicare UPIN
WV7103195000Medicaid
WV2023164Medicare PIN