Healthcare Provider Details

I. General information

NPI: 1952991242
Provider Name (Legal Business Name): KASSANDRA PEARL CRISWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 10/29/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MEDICAL CENTER DR STE 203
PADUCAH KY
42003-7907
US

IV. Provider business mailing address

1530 LONE OAK RD
PADUCAH KY
42003
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-6100
  • Fax:
Mailing address:
  • Phone: 270-415-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3015708
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number3015708
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: