Provider Demographics
NPI:1689730616
Name:CRISP, CAROL D (PHD, MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:D
Last Name:CRISP
Suffix:
Gender:F
Credentials:PHD, MSN, FNP-BC
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:D
Other - Last Name:MICSUNESCU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3265 HILLCREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7657
Mailing Address - Country:US
Mailing Address - Phone:541-275-6655
Mailing Address - Fax:
Practice Address - Street 1:3312 GATEWAY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1054
Practice Address - Country:US
Practice Address - Phone:541-204-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNP61599363LF0000X
OR10002835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10002835OtherSTATE LICENSE
IDCNP61599OtherSTATE LICENSE