Healthcare Provider Details

I. General information

NPI: 1215579156
Provider Name (Legal Business Name): STEPHANIE LEE CRAWFORD PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W BROADWAY # DE
FARMINGTON NM
87401-5638
US

IV. Provider business mailing address

1001 W BROADWAY # DE
FARMINGTON NM
87401-5638
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4796
  • Fax: 505-599-9351
Mailing address:
  • Phone: 505-327-4796
  • Fax: 55-999-3515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number57133
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number57133
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: