Provider Demographics
NPI:1003099052
Name:CREWS, FALLON (APRN)
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:CREWS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-0280
Mailing Address - Country:US
Mailing Address - Phone:850-932-5055
Mailing Address - Fax:850-934-1404
Practice Address - Street 1:400 GULF BREEZE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4458
Practice Address - Country:US
Practice Address - Phone:850-932-5055
Practice Address - Fax:850-932-1404
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN226921363LP0200X
FLAPRN9267229363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129611Medicaid