Provider Demographics
NPI:1043965957
Name:CRISMAN, KATIE JUSTINE (CRNA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JUSTINE
Last Name:CRISMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JUSTINE
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:323 GOLDRUSH LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72405-5141
Mailing Address - Country:US
Mailing Address - Phone:720-937-0855
Mailing Address - Fax:
Practice Address - Street 1:4800 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8413
Practice Address - Country:US
Practice Address - Phone:870-936-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
AR220477367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program