Provider Demographics
NPI:1033092903
Name:FOUR CROWNE LEGACY LLC
Entity type:Organization
Organization Name:FOUR CROWNE LEGACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDNORA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, PMHNP
Authorized Official - Phone:757-342-5461
Mailing Address - Street 1:317 PEACH TREE CRES
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-7494
Mailing Address - Country:US
Mailing Address - Phone:757-504-2191
Mailing Address - Fax:
Practice Address - Street 1:6147 JEFFERSON AVE OFC 2
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-1511
Practice Address - Country:US
Practice Address - Phone:757-504-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care