Provider Demographics
NPI:1336261627
Name:CRUDUP, BENNIE EDWARD (LPN)
Entity type:Individual
Prefix:
First Name:BENNIE
Middle Name:EDWARD
Last Name:CRUDUP
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 WINN WAY
Mailing Address - Street 2:RM 2118
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1715
Mailing Address - Country:US
Mailing Address - Phone:404-508-7857
Mailing Address - Fax:404-508-7826
Practice Address - Street 1:440 WINN WAY
Practice Address - Street 2:RM 2118
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1715
Practice Address - Country:US
Practice Address - Phone:404-508-7857
Practice Address - Fax:404-508-7826
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN067878164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse