Healthcare Provider Details

I. General information

NPI: 1205254216
Provider Name (Legal Business Name): THERESA LEE CRAWFORD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA D LEE FNP

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26136 HWY 59
FAIRFAX MO
64446-0446
US

IV. Provider business mailing address

26136 HWY 59 PO BOX 7
FAIRFAX MO
64446-0446
US

V. Phone/Fax

Practice location:
  • Phone: 660-686-2211
  • Fax: 660-686-2522
Mailing address:
  • Phone: 660-686-2211
  • Fax: 660-686-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2000163428
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: