Basic Information
| Provider Information | |||||||||
| NPI: | 1083256382 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CMEYLA | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228603 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1350 CLEVELAND ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296072440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645224888 | ||||||||
| FaxNumber: | 8645224885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2019 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 23067 | SC | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363LF0000X | 23067 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP2690 | 05 | SC | MEDICAID | NP6290 | 05 | SC | MEDICAID |