Provider Demographics
NPI:1396971339
Name:CRANDALL, JEAN WINIFRED I (ANP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:WINIFRED
Last Name:CRANDALL
Suffix:I
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-5708
Mailing Address - Country:US
Mailing Address - Phone:845-651-1483
Mailing Address - Fax:845-651-1487
Practice Address - Street 1:10 CLARK RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-5708
Practice Address - Country:US
Practice Address - Phone:845-651-1483
Practice Address - Fax:845-651-1487
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300830363LA2200X
NJ26NJ00042900363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS47826Medicare UPIN