Healthcare Provider Details

I. General information

NPI: 1588402820
Provider Name (Legal Business Name): LAUREN ROCHELLE CRIMM AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 07/19/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 COUNTRY CLUB RD
FAIRMONT WV
26554-1306
US

IV. Provider business mailing address

PO BOX 128
WEST ALEXANDER PA
15376-0128
US

V. Phone/Fax

Practice location:
  • Phone: 304-366-9100
  • Fax:
Mailing address:
  • Phone: 724-263-5061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number119208
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: