Healthcare Provider Details

I. General information

NPI: 1417543414
Provider Name (Legal Business Name): ANTONDE TYESE CRAWFORD HAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8334 PINEVILLE MATTHEWS RD STE 102
CHARLOTTE NC
28226-3764
US

IV. Provider business mailing address

8334 PINEVILLE MATTHEWS RD STE 102
CHARLOTTE NC
28226-3764
US

V. Phone/Fax

Practice location:
  • Phone: 704-541-8965
  • Fax:
Mailing address:
  • Phone: 704-541-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1573
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: