Basic Information
Provider Information | |||||||||
NPI: | 1467628503 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RHODES | ||||||||
FirstName: | CHRYSTAL | ||||||||
MiddleName: | ELAINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BISHOP | ||||||||
OtherFirstName: | CHRYSTAL | ||||||||
OtherMiddleName: | ELAINE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2000 HEALTH PARK DR FL HP2 | ||||||||
Address2: |   | ||||||||
City: | BRENTWOOD | ||||||||
State: | TN | ||||||||
PostalCode: | 370274692 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153737600 | ||||||||
FaxNumber: | 8663461426 | ||||||||
Practice Location | |||||||||
Address1: | 4615 HUNTRIDGE RD | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240128510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5409770900 | ||||||||
FaxNumber: | 5409770550 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/07/2008 | ||||||||
LastUpdateDate: | 12/06/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/06/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 0001169390 | VA | N |   | Nursing Service Providers | Registered Nurse |   | 363L00000X | 0024169391 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1467628503 | 05 | VA |   | MEDICAID |