Provider Demographics
NPI:1568442382
Name:CROOKSHANKS, TAMMY L (CFNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:CROOKSHANKS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:L
Other - Last Name:HENDRICKS/MULLENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:800 GRAND CENTRAL MALL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4100
Mailing Address - Country:US
Mailing Address - Phone:304-485-3300
Mailing Address - Fax:304-485-3317
Practice Address - Street 1:800 GRAND CENTRAL MALL
Practice Address - Street 2:SUITE 4
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-4100
Practice Address - Country:US
Practice Address - Phone:304-485-3300
Practice Address - Fax:304-485-3317
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV29894363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQ56011Medicare UPIN
WVCRNP19581Medicare ID - Type UnspecifiedMEDICARE NUMBER