MEDICARE: MRS. CAROL ANN MARIE DOUGLAS-CRENSHAW CHHA/CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	372600000X	Adult Companion
2	374U00000X	Home Health Aide
3	374U00000X	Home Health Aide	26NH11551000	NJ
4	376K00000X	Nurse's Aide

General Provider Information

NPI Number	:	1558690735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL ANN MARIE DOUGLAS-CRENSHAW CHHA/CNA

Provider Business Mailing Address
First Line	:	955 S SPRINGFIELD AVE # 2406
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3543
Country	:	US
Telephone Number	:	973-336-7969
Fax Number	:

Provider Business Practice Location Address
First Line	:	955 S SPRINGFIELD AVE # 2406
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3543
Country	:	US
Telephone Number	:	973-336-7969
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2009
Last Update Date	:	12/16/2009

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