Basic Information
| Provider Information | |||||||||
| NPI: | 1891070629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUPKA | ||||||||
| FirstName: | CHARMAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | CNM, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | CHARMAINE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 20TH AVE N STE 403 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372035180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152847283 | ||||||||
| FaxNumber: | 6152847501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4928 EDMONDSON PIKE STE 205 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372114791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152221400 | ||||||||
| FaxNumber: | 6152221410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 16156 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LF0000X | 16156 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | T00242A | 01 | TN | MEDICARE | OTHER | Q034583 | 05 | TN | MEDICAID |