Provider Demographics
NPI:1295579951
Name:CRUM, AMY ROSE (APNP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:CRUM
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ROSE
Other - Last Name:BIRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4536 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-5917
Mailing Address - Country:US
Mailing Address - Phone:262-771-1695
Mailing Address - Fax:262-885-6340
Practice Address - Street 1:4536 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5917
Practice Address - Country:US
Practice Address - Phone:262-771-1695
Practice Address - Fax:262-885-6340
Is Sole Proprietor?:No
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15474-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health