Healthcare Provider Details

I. General information

NPI: 1295709475
Provider Name (Legal Business Name): JEANNINE CROMWELL LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 GRAPE AVE
ST CLOUD FL
34769
US

IV. Provider business mailing address

1875 BOGGY CREEK RD
KISSIMMEE FL
34744-9516
US

V. Phone/Fax

Practice location:
  • Phone: 407-943-8677
  • Fax: 407-892-6468
Mailing address:
  • Phone: 407-943-8677
  • Fax: 407-892-6468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN695961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: