1003655572 NPI number — REBECCA CRIMMINS

Table of content: REBECCA CRIMMINS (NPI 1003655572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003655572 NPI number — REBECCA CRIMMINS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRIMMINS
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KLOTZ
Provider Other First Name:
REBECCA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003655572
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 HEALTH DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-6592
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 E VISTULA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRISTOL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46507-9489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-848-4427
Provider Business Practice Location Address Fax Number:
574-848-4592
Provider Enumeration Date:
05/23/2024

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: 363LF0000X , with the licence number:  71015427A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300095456 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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