Provider Demographics
NPI:1952991242
Name:CRISWELL, KASSANDRA PEARL (NP)
Entity Type:Individual
Prefix:MRS
First Name:KASSANDRA
Middle Name:PEARL
Last Name:CRISWELL
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 1:225 MEDICAL CENTER DR STE 203
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7907
Mailing Address - Country:US
Mailing Address - Phone:270-703-8411
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DR STE 203
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7907
Practice Address - Country:US
Practice Address - Phone:270-415-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015708363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care