Healthcare Provider Details

I. General information

NPI: 1386759819
Provider Name (Legal Business Name): MARIE CRISPIN ANDERSON RN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST WOODROW WILSON DR MEDICAL SERVICE ROUTING NUMBER 111A
JACKSON MS
39216-5199
US

IV. Provider business mailing address

102 ELGIN PLACE
CLINTON MS
39056-3946
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-364-1278
Mailing address:
  • Phone: 601-925-0890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR532606
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: