Basic Information
Provider Information | |||||||||
NPI: | 1568667384 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOLEY | ||||||||
FirstName: | CRYSTAL | ||||||||
MiddleName: | J. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JAMES | ||||||||
OtherFirstName: | CRYSTAL | ||||||||
OtherMiddleName: | HARRIET | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 13 CLUB DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296051205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642551000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 SAINT FRANCIS DR | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296013955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642551000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2007 | ||||||||
LastUpdateDate: | 07/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2700 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 30210120 | 01 | SC | FIRSTCHOICE, SELECT HEALTH | OTHER | NPI # | 01 | SC | BLUE CHOICE COMMERCIAL PLANS | OTHER | NPI # | 01 | SC | BLUE CROSS NETWORKS | OTHER | 1068772 | 01 | SC | WELLCARE | OTHER | NPI # | 01 | SC | TRICARE SOUTH REGION | OTHER | NPI # | 01 | SC | BLUE CHOICE MEDICAID | OTHER | 003159119A | 05 | GA |   | MEDICAID | AN1402 | 05 | SC |   | MEDICAID |