Healthcare Provider Details

I. General information

NPI: 1649109794
Provider Name (Legal Business Name): SHAKETHA CRUTCHFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 MINNEHAHA AVE STE 130 #11
MINNEAPOLIS MN
55406
US

IV. Provider business mailing address

2740 MINNEHAHA AVE STE 130 #11
MINNEAPOLIS MN
55406
US

V. Phone/Fax

Practice location:
  • Phone: 612-505-2602
  • Fax:
Mailing address:
  • Phone: 612-505-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: