=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235583105
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CORA SIMS CRUMBY CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2016
-----------------------------------------------------
Last Update Date | 03/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3950 COBB PKWY NW
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-9532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-889-0487
-----------------------------------------------------
Fax | 866-493-3521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 SNAP DRAGON LN
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30132-0856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 915-202-4370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | RN234960
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------