Healthcare Provider Details

I. General information

NPI: 1730546243
Provider Name (Legal Business Name): GABRIEL CRAWFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4217 SCENIC VIEW DR
FARMINGTON MO
63640-7846
US

IV. Provider business mailing address

4217 SCENIC VIEW DR
FARMINGTON MO
63640-7846
US

V. Phone/Fax

Practice location:
  • Phone: 573-330-6468
  • Fax: 573-218-0716
Mailing address:
  • Phone: 573-330-6468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2084P0800X
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code193400000X
TaxonomySingle Specialty Group
License Number2084P0800X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: