Healthcare Provider Details

I. General information

NPI: 1801237391
Provider Name (Legal Business Name): PENNY PICKLE KRISPIN RN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4702 WESLEY ST STE B
GREENVILLE TX
75401-5663
US

IV. Provider business mailing address

4702 WESLEY ST STE B
GREENVILLE TX
75401-5663
US

V. Phone/Fax

Practice location:
  • Phone: 903-450-0710
  • Fax: 903-306-1168
Mailing address:
  • Phone: 903-450-0710
  • Fax: 903-306-1168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number510151
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number510151
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: