Provider Demographics
NPI:1578021135
Name:CRULL, CARLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:CRULL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 FARMERS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-9791
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2019-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291722363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care