Provider Demographics
NPI:1184353096
Name:LEGIONS-HOLDEN, CRYSTAL MICHELLE (AGACNP)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:LEGIONS-HOLDEN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27A MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3949
Mailing Address - Country:US
Mailing Address - Phone:731-524-3310
Mailing Address - Fax:731-424-4109
Practice Address - Street 1:27A MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3949
Practice Address - Country:US
Practice Address - Phone:731-524-3310
Practice Address - Fax:731-424-4109
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN83163WR0006X
TN31707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant