Provider Demographics
NPI:1801237391
Name:PICKLE KRISPIN, PENNY (RN NP-C)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:PICKLE KRISPIN
Suffix:
Gender:F
Credentials:RN NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 WESLEY ST STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-5663
Mailing Address - Country:US
Mailing Address - Phone:903-450-0710
Mailing Address - Fax:903-306-1168
Practice Address - Street 1:4702 WESLEY ST STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5663
Practice Address - Country:US
Practice Address - Phone:903-450-0710
Practice Address - Fax:903-306-1168
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX510151363LF0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX380143302Medicaid