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General NPI Number Information
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NPI Number | 1033092903
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Entity Type | Organization
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Legal Business Name | FOUR CROWNE LEGACY LLC
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Dates
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Enumeration Date | 07/29/2025
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Last Update Date | 11/24/2025
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Provider Practice Location Address
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Address Line | 6147 JEFFERSON AVE OFC 2
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City | NEWPORT NEWS
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State | VA
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Zip | 23605-1511
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Country | US
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Telephone | 757-504-2191
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Fax |
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Provider Business Mailing Address
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Address Line | 317 PEACH TREE CRES
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City | NEWPORT NEWS
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State | VA
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Zip | 23602-7494
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Country | US
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Telephone | 757-504-2191
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DR. EDNORA BRADLEY MASON
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Credential | DNP, APRN, PMHNP-BC
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Telephone | 757-826-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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