Healthcare Provider Details

I. General information

NPI: 1215576905
Provider Name (Legal Business Name): MARY ANN CROW FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 QUAIL TRL
EDGEWOOD NM
87015-7185
US

IV. Provider business mailing address

168 SANGRE DE CRISTO
CEDAR CREST NM
87008-9402
US

V. Phone/Fax

Practice location:
  • Phone: 505-208-0204
  • Fax:
Mailing address:
  • Phone: 505-715-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number58824
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: