1215483094 NPI number — MRS. SHANTRYCE MONIQUE BOATWRIGHT CRUMP RDH

Table of content: MRS. SHANTRYCE MONIQUE BOATWRIGHT CRUMP RDH (NPI 1215483094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215483094 NPI number — MRS. SHANTRYCE MONIQUE BOATWRIGHT CRUMP RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOATWRIGHT CRUMP
Provider First Name:
SHANTRYCE
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOATWRIGHT
Provider Other First Name:
SHANTRYCE
Provider Other Middle Name:
MONIQUE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RDH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215483094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2617 RIELLY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-643-2219
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2617 RIELLY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-643-2219
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2016

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: 124Q00000X , with the licence number:  8117 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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