Provider Demographics
NPI:1962044800
Name:CRUCE, CHARLIE J
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:J
Last Name:CRUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:J
Other - Last Name:GOBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:300 S SCHOOL ST
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638-2127
Practice Address - Country:US
Practice Address - Phone:870-538-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR122323363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily