Provider Demographics
NPI:1477619443
Name:CRANDELL, TERESA L
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:CRANDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BROWN'S
Other - Middle Name:
Other - Last Name:SHOE STORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:104 S MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-5022
Mailing Address - Country:US
Mailing Address - Phone:918-756-2111
Mailing Address - Fax:
Practice Address - Street 1:104 S MORTON AVE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5022
Practice Address - Country:US
Practice Address - Phone:918-756-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor