Provider Demographics
NPI:1689845182
Name:CRISP, CLOVA E (RPN)
Entity Type:Individual
Prefix:MRS
First Name:CLOVA
Middle Name:E
Last Name:CRISP
Suffix:
Gender:F
Credentials:RPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 CASSA LOOP
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2622
Mailing Address - Country:US
Mailing Address - Phone:631-758-2414
Mailing Address - Fax:
Practice Address - Street 1:322 CASSA LOOP
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-2622
Practice Address - Country:US
Practice Address - Phone:631-758-2414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY505112-1163W00000X, 163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology