Healthcare Provider Details

I. General information

NPI: 1962468678
Provider Name (Legal Business Name): CRESFIELD WINSLOW MOODY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 S. LAKE POWELL BLVD
PAGE AZ
86040-0790
US

IV. Provider business mailing address

PO BOX 790 463 S. LAKE POWELL BLVD
PAGE AZ
86040-0790
US

V. Phone/Fax

Practice location:
  • Phone: 928-645-0945
  • Fax: 925-645-3254
Mailing address:
  • Phone: 928-645-0945
  • Fax: 928-645-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP2197
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: