Healthcare Provider Details

I. General information

NPI: 1255402350
Provider Name (Legal Business Name): EVELYN SMALL CROUCH NP, CNM, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 RESPONSE RD
SACRAMENTO CA
95815-4807
US

IV. Provider business mailing address

1650 RESPONSE RD
SACRAMENTO CA
95815-4807
US

V. Phone/Fax

Practice location:
  • Phone: 916-614-4170
  • Fax:
Mailing address:
  • Phone: 919-454-4207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number322388
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: