1891794020 NPI number — MRS. AMANDA KIMBLE CRAWFORD CPNP

Table of content: MRS. AMANDA KIMBLE CRAWFORD CPNP (NPI 1891794020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891794020 NPI number — MRS. AMANDA KIMBLE CRAWFORD CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAWFORD
Provider First Name:
AMANDA
Provider Middle Name:
KIMBLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIMBLE
Provider Other First Name:
AMANDA
Provider Other Middle Name:
MECHE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891794020
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2051 SILVERSIDE DR
Provider Second Line Business Mailing Address:
STE 260
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-9005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-490-6301
Provider Business Mailing Address Fax Number:
225-765-9539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8415 GOODWOOD BLVD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70806-7851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-5633
Provider Business Practice Location Address Fax Number:
225-765-5634
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  RN096204 AP04552 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1468789 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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