Healthcare Provider Details

I. General information

NPI: 1861105140
Provider Name (Legal Business Name): DOLLY P CRESPO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 01/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 MAIN DR
FAYETTEVILLE AR
72704-5292
US

IV. Provider business mailing address

413 GREENLAND RD APT 206
TONTITOWN AR
72762-5317
US

V. Phone/Fax

Practice location:
  • Phone: 479-485-1215
  • Fax:
Mailing address:
  • Phone: 318-308-9848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number026351
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: