Provider Demographics
NPI:1205846813
Name:CROSSE-SUMLIN, MARIE CHANTALE (APRN)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CHANTALE
Last Name:CROSSE-SUMLIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:CHANTAL
Other - Last Name:SUMLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:4327 E BLACK CANYON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5875
Mailing Address - Country:US
Mailing Address - Phone:479-409-9973
Mailing Address - Fax:903-209-2907
Practice Address - Street 1:4285 N SHILOH DR STE 104
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5351
Practice Address - Country:US
Practice Address - Phone:479-320-8588
Practice Address - Fax:903-209-2907
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01830ANP363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155918758Medicaid
P30448Medicare UPIN
5Y215Medicare ID - Type Unspecified