Provider Demographics
NPI:1144825415
Name:CRUMBLISS, MARY (MSN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CRUMBLISS
Suffix:
Gender:F
Credentials:MSN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 FOX TROT TRL
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-7367
Mailing Address - Country:US
Mailing Address - Phone:423-838-3300
Mailing Address - Fax:
Practice Address - Street 1:388 FOX TROT TRL
Practice Address - Street 2:
Practice Address - City:RINGGOLD
Practice Address - State:GA
Practice Address - Zip Code:30736-7367
Practice Address - Country:US
Practice Address - Phone:423-838-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000028490363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics