Provider Demographics
NPI:1215010129
Name:CROMELL, CANDY R (NPC)
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:R
Last Name:CROMELL
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2698 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-8818
Mailing Address - Country:US
Mailing Address - Phone:970-298-2800
Mailing Address - Fax:970-298-6902
Practice Address - Street 1:2698 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8818
Practice Address - Country:US
Practice Address - Phone:970-298-2800
Practice Address - Fax:970-298-6902
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO112579363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO93037325Medicaid
CO93037325Medicaid
CO801569Medicare ID - Type Unspecified