=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376042069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA LOUISE CRAWFORD PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2018
-----------------------------------------------------
Last Update Date | 02/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 W HARRISON ST
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-631-3552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4217 SCENIC VIEW DR
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63640-7846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-631-3552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 2018004473
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------