Provider Demographics
NPI:1912095233
Name:CRUMLEY-FOREST, ROY EDWARD (ARNP)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:EDWARD
Last Name:CRUMLEY-FOREST
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 HENDRICKS AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-4217
Mailing Address - Country:US
Mailing Address - Phone:904-398-8266
Mailing Address - Fax:904-396-4803
Practice Address - Street 1:3129 HENDRICKS AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4217
Practice Address - Country:US
Practice Address - Phone:904-398-8266
Practice Address - Fax:904-396-4803
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1560042363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S72416Medicare UPIN
FLE2029XMedicare PIN