Healthcare Provider Details

I. General information

NPI: 1053086348
Provider Name (Legal Business Name): REBECCA DIANE CRAWFORTH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 04/11/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 REGENT ST STE 200
COLUMBUS OH
43219-6229
US

IV. Provider business mailing address

3944 N HERITAGE VIEW AVE
MERIDIAN ID
83646-6313
US

V. Phone/Fax

Practice location:
  • Phone: 877-870-1775
  • Fax: 614-968-8840
Mailing address:
  • Phone: 801-884-8030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number69178
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: