Provider Demographics
NPI:1366715112
Name:CRUTCHFIELD, MARY G (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:CRUTCHFIELD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 LASKIN RD
Mailing Address - Street 2:STE 104
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6387
Mailing Address - Country:US
Mailing Address - Phone:757-648-8605
Mailing Address - Fax:757-648-1363
Practice Address - Street 1:1072 LASKIN RD
Practice Address - Street 2:STE 104
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6387
Practice Address - Country:US
Practice Address - Phone:757-628-8605
Practice Address - Fax:757-648-1363
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169848363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPAROtherMULTIPLAN
VA1366715112Medicaid
NC7005918Medicaid
VAPAROtherCORVEL
VAPAROtherUSA MANAGED CARE
VA-022OtherCHAMPUS/TRICARE
VA10090356NOtherOPTIMA HEALTH
VA1366715112OtherVIRGINIA PREMIER HEALTH PLAN
VAVV5283AMedicare PIN
VA1366715112OtherVIRGINIA PREMIER HEALTH PLAN