Healthcare Provider Details

I. General information

NPI: 1013281427
Provider Name (Legal Business Name): HEIDI K CRULL ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 S FREMONT AVE STE 3300
SPRINGFIELD MO
65804-2239
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-5200
  • Fax: 417-820-5220
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2011040496
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: