Healthcare Provider Details

I. General information

NPI: 1144825415
Provider Name (Legal Business Name): MARY CRUMBLISS MSN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 MEDLOCK BRIDGE RD STE 250
JOHNS CREEK GA
30097-1999
US

IV. Provider business mailing address

10710 MEDLOCK BRIDGE RD STE 250
JOHNS CREEK GA
30097-1999
US

V. Phone/Fax

Practice location:
  • Phone: 770-870-1085
  • Fax: 770-870-1086
Mailing address:
  • Phone: 770-870-1085
  • Fax: 770-870-1086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN298923
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPN0000028490
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: