Provider Demographics
NPI:1518770858
Name:CRISOSTOMO, CAROL CLAIRE (CRNP)
Entity type:Individual
Prefix:
First Name:CAROL CLAIRE
Middle Name:
Last Name:CRISOSTOMO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13598 ARCADIAN DR
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-5022
Mailing Address - Country:US
Mailing Address - Phone:612-345-2107
Mailing Address - Fax:
Practice Address - Street 1:818 W DIAMOND AVE STE 130
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1417
Practice Address - Country:US
Practice Address - Phone:301-409-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-30
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001281517163W00000X
MDAC007885363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse