Provider Demographics
NPI:1629669452
Name:CRISCILLIS, MELISSA (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CRISCILLIS
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 FAIRFIELD CT
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-1006
Mailing Address - Country:US
Mailing Address - Phone:803-215-9490
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180777363LA2100X, 363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care