Provider Demographics
NPI:1124295852
Name:CRENSHAW, MARISA L (APRN)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:L
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5722 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-4156
Mailing Address - Country:US
Mailing Address - Phone:502-921-0222
Mailing Address - Fax:502-921-0222
Practice Address - Street 1:5722 OUTER LOOP
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-4156
Practice Address - Country:US
Practice Address - Phone:502-921-0222
Practice Address - Fax:502-921-0222
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007792363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100230720Medicaid
IN201258840Medicaid
KY3007792OtherLICENSE
IN71004333AOtherLICENSE
KYK070070Medicare PIN
IN129980005Medicare PIN