Provider Demographics
NPI:1275183147
Name:CRISP, JODY PUCKETT (MSN-FNP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:PUCKETT
Last Name:CRISP
Suffix:
Gender:F
Credentials:MSN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 S ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28731-9447
Mailing Address - Country:US
Mailing Address - Phone:828-692-6178
Mailing Address - Fax:
Practice Address - Street 1:571 S ALLEN RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28731-9447
Practice Address - Country:US
Practice Address - Phone:828-692-6178
Practice Address - Fax:828-692-2365
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012460363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner