1295167484 NPI number — SHELLY LYNN CROSSMAN MSN, FNP-C

Table of content: SHELLY LYNN CROSSMAN MSN, FNP-C (NPI 1295167484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295167484 NPI number — SHELLY LYNN CROSSMAN MSN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROSSMAN
Provider First Name:
SHELLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRANZ
Provider Other First Name:
SHELLY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSN, FNP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1295167484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1042 WILLOW CREEK RD SUITE A101
Provider Second Line Business Mailing Address:
PO BOX 416
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301-1673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-499-2915
Provider Business Mailing Address Fax Number:
877-406-3180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
448 N STATE ROUTE 89 STE H
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHINO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86323-5957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-499-2915
Provider Business Practice Location Address Fax Number:
877-406-3180
Provider Enumeration Date:
07/30/2013

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: 363LF0000X , with the licence number:  F337984-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP11069 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: AP11069 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 395116 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".