Healthcare Provider Details

I. General information

NPI: 1598244915
Provider Name (Legal Business Name): TINA I CRAWFORD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2079 EDGEWATER DR
PEKIN IL
61554-7833
US

IV. Provider business mailing address

2079 EDGEWATER DR
PEKIN IL
61554-7833
US

V. Phone/Fax

Practice location:
  • Phone: 309-382-2006
  • Fax: 309-382-2007
Mailing address:
  • Phone: 309-382-2006
  • Fax: 309-382-2007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number041.320339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: