Basic Information
| Provider Information | |||||||||
| NPI: | 1457729139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENICK | ||||||||
| FirstName: | CRYSTAL | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3604 WATERWAY BLVD | ||||||||
| Address2: | |||||||||
| City: | ISLE OF PALMS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294512552 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 51 NASSAU ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437224112 | ||||||||
| FaxNumber: | 8435778960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 241914 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 19693 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.