Healthcare Provider Details

I. General information

NPI: 1962812099
Provider Name (Legal Business Name): KERRY A CRANDALL,ARNP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 CLYDE MORRIS BLVD
ORMOND BEACH FL
32174-8130
US

IV. Provider business mailing address

290 CLYDE MORRIS BLVD
ORMOND BEACH FL
32174-8130
US

V. Phone/Fax

Practice location:
  • Phone: 386-677-5600
  • Fax:
Mailing address:
  • Phone: 386-677-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberARNP2043932
License Number StateFL

VIII. Authorized Official

Name: MS. KERRY ANNE CRANDALL
Title or Position: ARNP
Credential: ARNP
Phone: 386-852-8505