Healthcare Provider Details

I. General information

NPI: 1770923153
Provider Name (Legal Business Name): MARTHA CRAWFORD R.N,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 N OUTER RD SUITE C
DEXTER MO
63841-8482
US

IV. Provider business mailing address

2106 N OUTER RD SUITE C
DEXTER MO
63841-8482
US

V. Phone/Fax

Practice location:
  • Phone: 573-820-9494
  • Fax:
Mailing address:
  • Phone: 573-820-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number123904
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: