MEDICARE: ANGELA NICOLE CRAWFORD NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	RN166954	GA

General Provider Information

NPI Number	:	1740792829
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA NICOLE CRAWFORD NP

Provider Business Mailing Address
First Line	:	4421 CARNES ST
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-5305
Country	:	US
Telephone Number	:	478-621-2072
Fax Number	:	678-540-8623

Provider Business Practice Location Address
First Line	:	4421 CARNES ST
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-5305
Country	:	US
Telephone Number	:	478-621-2072
Fax Number	:	678-540-8623

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2017
Last Update Date	:	10/30/2017

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