Basic Information
| Provider Information | |||||||||
| NPI: | 1154930170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARGRAVE | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | HOLT | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 OPITZ BLVD STE G-209 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221913311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035230611 | ||||||||
| FaxNumber: | 7036702089 | ||||||||
| Practice Location | |||||||||
| Address1: | 2300 OPITZ BLVD STE G-209 | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221913311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035230611 | ||||||||
| FaxNumber: | 7036702089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2020 | ||||||||
| LastUpdateDate: | 09/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 0024179481 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.