Healthcare Provider Details

I. General information

NPI: 1669893632
Provider Name (Legal Business Name): CAMILLE MCCRARY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAMILLE COBURN RN

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

1341 N HARLEM AVE APT 4
OAK PARK IL
60302-1333
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 708-689-7373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041394483
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number257107
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: