Provider Demographics
NPI:1144758756
Name:CRISWELL, BRANDI
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:CRISWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:TALLASSEE
Mailing Address - State:AL
Mailing Address - Zip Code:36078-1255
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:TALLASSEE
Practice Address - State:AL
Practice Address - Zip Code:36078-1255
Practice Address - Country:US
Practice Address - Phone:334-283-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-131647363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily