Basic Information
| Provider Information | |||||||||
| NPI: | 1790999480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUMBY | ||||||||
| FirstName: | CHARLENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN MSN FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOWARD | ||||||||
| OtherFirstName: | CHARLENE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5012 S US HWY 75, SUITE 300 | ||||||||
| Address2: | ATTN BILLING | ||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750204589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034166430 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5012 S US HIGHWAY 75 | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750204587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034166430 | ||||||||
| FaxNumber: | 9034166431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 01/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 231525 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 330235801 | 05 | TX | MEDICAID |