Provider Demographics
NPI:1144863051
Name:CRUMWELL-MACK, ELISHIA KATHLEEN
Entity type:Individual
Prefix:
First Name:ELISHIA
Middle Name:KATHLEEN
Last Name:CRUMWELL-MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 PHILIP BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8746
Mailing Address - Country:US
Mailing Address - Phone:770-822-5560
Mailing Address - Fax:770-822-4989
Practice Address - Street 1:301 PHILIP BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8746
Practice Address - Country:US
Practice Address - Phone:770-822-5560
Practice Address - Fax:770-822-4989
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN302384363L00000X
NYF309111-1207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty