Provider Demographics
NPI:1659859106
Name:CRUMP, SHAMEKA
Entity Type:Individual
Prefix:
First Name:SHAMEKA
Middle Name:
Last Name:CRUMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 WAYNELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-4041
Mailing Address - Country:US
Mailing Address - Phone:979-219-4861
Mailing Address - Fax:
Practice Address - Street 1:3201 UNIVERSITY DR E STE 280
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3490
Practice Address - Country:US
Practice Address - Phone:979-485-5451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-06
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily