Healthcare Provider Details

I. General information

NPI: 1588088090
Provider Name (Legal Business Name): STACEY CRAWFORD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5119 NE 57TH AVE
PORTLAND OR
97218-2584
US

IV. Provider business mailing address

9301 SW SAGERT ST APT 187
TUALATIN OR
97062-7032
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-8062
  • Fax:
Mailing address:
  • Phone: 503-895-7732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2007
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: