Provider Demographics
NPI:1659317675
Name:SMITH, CRYSTAL A (CNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 OLD MILTON PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2521
Mailing Address - Country:US
Mailing Address - Phone:470-267-0360
Mailing Address - Fax:770-999-2691
Practice Address - Street 1:2450 OLD MILTON PKWY STE 201
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2521
Practice Address - Country:US
Practice Address - Phone:470-267-0360
Practice Address - Fax:770-999-2691
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036068939363LF0000X
GARN309424363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036068939Medicaid
IL004750OtherHEALTH ALLIANCE
ILC41701Medicare UPIN
IL557210Medicare ID - Type UnspecifiedMEDICARE