Healthcare Provider Details

I. General information

NPI: 1619787686
Provider Name (Legal Business Name): ELIZABETH CRAWFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450077 STATE ROAD 200 STE 12
CALLAHAN FL
32011-3863
US

IV. Provider business mailing address

450077 STATE ROAD 200 STE 12
CALLAHAN FL
32011-3863
US

V. Phone/Fax

Practice location:
  • Phone: 904-633-0560
  • Fax:
Mailing address:
  • Phone: 904-502-1529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11037557
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: