Provider Demographics
NPI:1912142464
Name:CRANDALL, TIM (LPN)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 HANNUM RD
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-9764
Mailing Address - Country:US
Mailing Address - Phone:716-269-9423
Mailing Address - Fax:
Practice Address - Street 1:1680 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4914
Practice Address - Country:US
Practice Address - Phone:716-894-7777
Practice Address - Fax:716-894-0604
Is Sole Proprietor?:No
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275912164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse