Provider Demographics
NPI:1629544630
Name:CRUMPLER, KELLEY CHAMP (LVN)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:CHAMP
Last Name:CRUMPLER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 MILLS PARK CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-1100
Mailing Address - Country:US
Mailing Address - Phone:979-402-3714
Mailing Address - Fax:
Practice Address - Street 1:4508 MILLS PARK CIR STE 100
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-1100
Practice Address - Country:US
Practice Address - Phone:979-402-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195614164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX46-4404759OtherMEDICAL BUSINESS TIN