1790479152 NPI number — PAMELA PROCTOR CRISCITIELLO AGPCNP, MSN, RN, OCN

Table of content: PAMELA PROCTOR CRISCITIELLO AGPCNP, MSN, RN, OCN (NPI 1790479152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790479152 NPI number — PAMELA PROCTOR CRISCITIELLO AGPCNP, MSN, RN, OCN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISCITIELLO
Provider First Name:
PAMELA
Provider Middle Name:
PROCTOR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGPCNP, MSN, RN, OCN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790479152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
812 PINE VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGE STATION
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77845-4460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-298-8973
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 E VILLA MARIA RD STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRYAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77802-2585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-776-2000
Provider Business Practice Location Address Fax Number:
866-733-2572
Provider Enumeration Date:
06/07/2023

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: 363LA2200X , with the licence number:  AG05230129 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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