Basic Information
| Provider Information | |||||||||
| NPI: | 1043475171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISP | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BSN RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAMBY | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BSN RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 64 JOHN CROWE RD | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 64 JOHN CROWE RD | ||||||||
| Address2: | |||||||||
| City: | CHEROKEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284979163 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2008 | ||||||||
| LastUpdateDate: | 07/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 68211 | SC | Y | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 8600501 | 05 | NC | MEDICAID | 68211 | 01 | NC | RN | OTHER |