Provider Demographics
NPI:1992094130
Name:CRICKENBERGER, STEPHANIE L (FNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:CRICKENBERGER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:C
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:61 WHITCHER ST NE
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1176
Mailing Address - Country:US
Mailing Address - Phone:770-422-3290
Mailing Address - Fax:770-422-0287
Practice Address - Street 1:61 WHITCHER ST NE
Practice Address - Street 2:SUITE 1100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1176
Practice Address - Country:US
Practice Address - Phone:770-422-3290
Practice Address - Fax:770-422-0287
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102799363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122295CMedicaid
GA003122295DMedicaid
GA202I503999Medicare PIN