Provider Demographics
NPI:1942421045
Name:CRISPELL, PRISCILLA CANTINE (NP)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:CANTINE
Last Name:CRISPELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CAMPBELL AVE.
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-272-5927
Mailing Address - Fax:607-273-0373
Practice Address - Street 1:LAKESIDE NURSING HOME, INC.
Practice Address - Street 2:1229 TRUMANSBURG RD
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1313
Practice Address - Country:US
Practice Address - Phone:607-273-8072
Practice Address - Fax:607-273-0373
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3021451363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P19651Medicare UPIN