=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790195675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER FENLEY CRABTREE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2014
-----------------------------------------------------
Last Update Date | 01/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3670 S BENZING RD STE C
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-300-2577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3670 S BENZING RD STE C
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127-1741
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-300-2577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 73244
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 318450-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------