=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740792829
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA NICOLE CRAWFORD NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2017
-----------------------------------------------------
Last Update Date | 10/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4421 CARNES ST
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-621-2072
-----------------------------------------------------
Fax | 678-540-8623
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4421 CARNES ST
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-621-2072
-----------------------------------------------------
Fax | 678-540-8623
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | RN166954
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------