Provider Demographics
NPI:1346893161
Name:CRISWELL, JODY CHRISTOPHER (NP)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:CHRISTOPHER
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3726
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3726
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-868-8375
Practice Address - Street 1:3647 J DEWEY GRAY CIR STE 200
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2205
Practice Address - Country:US
Practice Address - Phone:706-504-9712
Practice Address - Fax:706-504-9703
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN194462363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care