Active NPI
Crystal Nichols Clark, LPTA
- Physical Therapy Assistant
- Rustburg, VA
National Provider Identifier
1104155480
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 2306001767
- Practice address
- 4968 Bethany Rd
Rustburg, VA 24588-3693 - Phone
- (434) 845-3554
- NPI assigned
- Dec 15, 2009
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 2306001767 | VA | Primary |
Addresses
Primary practice location
4968 Bethany Rd
Rustburg, VA 24588-3693
Mailing address
4968 Bethany Rd
Rustburg, VA 24588-3693
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2306001767 | VA | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1260835200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1260835200000",
"number": "1104155480",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4968 BETHANY RD",
"city": "RUSTBURG",
"state": "VA",
"postal_code": "245883693"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4968 BETHANY RD",
"city": "RUSTBURG",
"state": "VA",
"postal_code": "245883693",
"telephone_number": "434-845-3554"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CLARK",
"first_name": "CRYSTAL",
"middle_name": "NICHOLS",
"credential": "LPTA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2009-12-15",
"last_updated": "2009-12-15",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "VA",
"license": "2306001767",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Rustburg, VA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.