Provider Demographics
NPI:1275277238
Name:CRANDALL, KIMBERLY JO (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N HEMMER RD STE 211
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-9690
Mailing Address - Country:US
Mailing Address - Phone:907-203-4677
Mailing Address - Fax:907-745-3780
Practice Address - Street 1:1901 N HEMMER RD STE 211
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9690
Practice Address - Country:US
Practice Address - Phone:907-203-4677
Practice Address - Fax:907-745-3780
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNURR26951163W00000X
AK198965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse