Healthcare Provider Details

I. General information

NPI: 1205719770
Provider Name (Legal Business Name): MRS. TONYA LEE CRUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MAIN STREET
CHAPMANVILLE WV
25508
US

IV. Provider business mailing address

PO BOX 1637
CHAPMANVILLE WV
25508-1637
US

V. Phone/Fax

Practice location:
  • Phone: 304-688-9901
  • Fax: 304-688-9904
Mailing address:
  • Phone: 304-688-9901
  • Fax: 304-688-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number123976
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: