Provider Demographics
NPI:1861105140
Name:CRESPO, DOLLY P
Entity type:Individual
Prefix:
First Name:DOLLY
Middle Name:P
Last Name:CRESPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 GREENLAND RD APT 206
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72762-5317
Mailing Address - Country:US
Mailing Address - Phone:318-308-9848
Mailing Address - Fax:
Practice Address - Street 1:2211 MAIN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5292
Practice Address - Country:US
Practice Address - Phone:479-485-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR026351163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWDL39SSF603BOtherDRIVERS LICENSE