1548779408 NPI number — CRYSTAL MANSFIELD KLEMENC FNP-BC

Table of content: CRYSTAL MANSFIELD KLEMENC FNP-BC (NPI 1548779408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548779408 NPI number — CRYSTAL MANSFIELD KLEMENC FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEMENC
Provider First Name:
CRYSTAL
Provider Middle Name:
MANSFIELD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548779408
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5315 COLTMAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30028-5606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-789-0168
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3300 OLD MILTON PKWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30005-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-664-9299
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN202822 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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