Provider Demographics
NPI:1891002358
Name:CRANDALL, NICOLE YVONNE
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:YVONNE
Last Name:CRANDALL
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 1:2817 SHELBURNE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8909
Mailing Address - Country:US
Mailing Address - Phone:407-873-6101
Mailing Address - Fax:
Practice Address - Street 1:18425 NW 2ND AVE PH 5
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4524
Practice Address - Country:US
Practice Address - Phone:954-257-7473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-04
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist