Healthcare Provider Details

I. General information

NPI: 1205115425
Provider Name (Legal Business Name): KAY MARIE CRAWFORD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 10/24/2021
Certification Date: 10/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MOUNTAIN AVE SUITE A-104
UPLAND CA
91786-4359
US

IV. Provider business mailing address

12441 HELENA WAY
RANCHO CUCAMONGA CA
91739-2652
US

V. Phone/Fax

Practice location:
  • Phone: 909-931-1033
  • Fax: 909-981-8976
Mailing address:
  • Phone: 909-931-1033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: