Healthcare Provider Details

I. General information

NPI: 1558726380
Provider Name (Legal Business Name): CRISTIN CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRISTIN MCCLANAHAN

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

110 RUNNYMEADE DR
JACKSONVILLE NC
28540-4241
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4300
  • Fax:
Mailing address:
  • Phone: 404-702-2962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number0001247879
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPRN11003801
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: