Healthcare Provider Details

I. General information

NPI: 1689730616
Provider Name (Legal Business Name): CAROL D CRISP PHD, MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL D MICSUNESCU FNP

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/27/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 GATEWAY ST
SPRINGFIELD OR
97477-1054
US

IV. Provider business mailing address

3265 HILLCREST PARK DR
MEDFORD OR
97504-7657
US

V. Phone/Fax

Practice location:
  • Phone: 541-204-4745
  • Fax:
Mailing address:
  • Phone: 541-275-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP61599
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10002835
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: