Healthcare Provider Details

I. General information

NPI: 1467686154
Provider Name (Legal Business Name): HAYLEY MICHELLE CRANDALL IDMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49TH MEDICAL GROUP/SGPF 280 FIRST STREET, BLDG 23
HOLLOMAN AFB NM
88330-8273
US

IV. Provider business mailing address

49TH MEDICAL GROUP/SGPF 280 FIRST STREET, BLDG 23
HOLLOMAN AFB NM
88330-8273
US

V. Phone/Fax

Practice location:
  • Phone: 575-572-2446
  • Fax: 575-572-2259
Mailing address:
  • Phone: 575-572-2446
  • Fax: 575-572-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: