Crystal Nichole Wallace, NP-C

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

902669 Issued in MS

Practice address

7148 U S Highway 98 Ste 102
Hattiesburg, MS 39402-9133

Phone

(601) 475-8270

Fax

(769) 207-6209

NPI assigned

Aug 29, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MS

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Nurse Practitioner

Education

Other, 2018

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Hattiesburg Clinic PAGroup PAC ID 5193706794, 525 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

State licenses

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: cwalllace138373@directpatientrecord.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Hattiesburg Clinic PA

  • Multi-Specialty Clinic/Center
  • Hattiesburg, MS
  • NPI 1740213446
  Medicare reassignment Care Compare group NPD
• Fast Pace Mississippi, PLLC

  • Rural Health Clinic/Center
  • Ripley, MS
  • NPI 1447769559

  Nurse Practitioner

  Medicare reassignment NPD
• Fast Pace Mississippi, PLLC

  • Rural Health Clinic/Center
  • Kosciusko, MS
  • NPI 1851050579
  NPD
• Hattiesburg Clinic, PA

  • Primary Care Clinic/Center
  • Flowood, MS
  • NPI 1912600354
  NPD
• Hattiesburg Clinic, PA

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Laurel, MS
  • NPI 1245263540
  NPD (past)
• State of Mississippi - University of Mississippi Medical Center

  • Critical Access Hospital
  • Lexington, MS
  • NPI 1386630705
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1535500800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1748822400000",
    "number": "1629550496",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3 CARRINGTON CT",
            "city": "HATTIESBURG",
            "state": "MS",
            "postal_code": "394028114",
            "telephone_number": "601-810-8996"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7148 U S HIGHWAY 98 STE 102",
            "city": "HATTIESBURG",
            "state": "MS",
            "postal_code": "394029133",
            "telephone_number": "601-475-8270",
            "fax_number": "769-207-6209"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "106 Asbury Cir",
            "address_purpose": "LOCATION",
            "city": "Hattiesburg",
            "state": "MS",
            "postal_code": "394021302",
            "country_code": "US",
            "telephone_number": "601-268-8698",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "50 Parkway Ln Ste B",
            "address_purpose": "LOCATION",
            "city": "Petal",
            "state": "MS",
            "postal_code": "394653035",
            "country_code": "US",
            "telephone_number": "601-705-2897",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALLACE",
        "first_name": "CRYSTAL",
        "middle_name": "NICHOLE",
        "credential": "NP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-08-29",
        "last_updated": "2025-06-02",
        "certification_date": "2025-06-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "MS",
            "license": "902669",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Scott Evans Walker, CRNA
• Sue D Walker, MD
• Tara Walker, LMSW
• Zachary Russell Walker, ATC
• Anna Christian Wall
• Felder E Wallace, D.D.S.
• Gwendolyn Deane Wallace, MS-CF,SLP
• Susan R Wallace
• Erik Waller
• William Lowe Waller III, MD

• Nurse Practitioner in Hattiesburg, MS
• Providers in Hattiesburg, MS by specialty
• Nurse Practitioner in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 2, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.