Healthcare Provider Details

I. General information

NPI: 1548443104
Provider Name (Legal Business Name): THERESA M CRULL N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 W PEORIA AVE
GLENDALE AZ
85302-2023
US

IV. Provider business mailing address

4494 W PEORIA AVENUE
GLENDALE AZ
85302-0000
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-5232
  • Fax:
Mailing address:
  • Phone: 623-486-5232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN034207
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: