Provider Demographics
NPI:1609383629
Name:MORING, CRYSTAL B (NP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:B
Last Name:MORING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:NIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:102 W PINELOCH AVE STE 23
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-6100
Mailing Address - Country:US
Mailing Address - Phone:407-635-5060
Mailing Address - Fax:321-842-9869
Practice Address - Street 1:102 W PINELOCH AVE STE 23
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-6100
Practice Address - Country:US
Practice Address - Phone:407-635-5060
Practice Address - Fax:321-842-9869
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11028964363LA2200X
VA0024175633363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121749600Medicaid