Provider Demographics
NPI:1861408965
Name:CREWS, KELLI M
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:CREWS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:MCCALL
Other - Last Name:CREWS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:619 SOUTH MARION STREET
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5808
Mailing Address - Country:US
Mailing Address - Phone:386-755-3016
Mailing Address - Fax:386-754-6408
Practice Address - Street 1:619 SOUTH MARION STREET
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-754-6408
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9180766363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health