1104932623 NPI number — MISS LYNNE M LACEY CRANDALL MS, CNS, ARNP

Table of content: MISS LYNNE M LACEY CRANDALL MS, CNS, ARNP (NPI 1104932623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104932623 NPI number — MISS LYNNE M LACEY CRANDALL MS, CNS, ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACEY CRANDALL
Provider First Name:
LYNNE
Provider Middle Name:
M
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MS, CNS, ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104932623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13815 TAMIAMI TRL
Provider Second Line Business Mailing Address:
NORTH PORT MEDICAL CENTER
Provider Business Mailing Address City Name:
NORTH PORT
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34287-2069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-426-4900
Provider Business Mailing Address Fax Number:
941-426-3994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13815 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
NORTH PORT MEDICAL CENTER
Provider Business Practice Location Address City Name:
NORTH PORT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34287-2069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-426-4900
Provider Business Practice Location Address Fax Number:
941-426-3994
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  ARNP3380712 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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