Provider Demographics
NPI:1306883418
Name:CRUM, BRENDA RAE (CFNP)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:RAE
Last Name:CRUM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:R
Other - Last Name:PETERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CFNP
Mailing Address - Street 1:2280 OPITZ BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3362
Mailing Address - Country:US
Mailing Address - Phone:703-523-8880
Mailing Address - Fax:757-648-1954
Practice Address - Street 1:2280 OPITZ BLVD STE 110
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3362
Practice Address - Country:US
Practice Address - Phone:703-523-8880
Practice Address - Fax:757-648-1954
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24131318163WM0705X
VA0024131318363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7792085Medicaid
VA7792085Medicaid
DC001542N63Medicare ID - Type Unspecified
VA500000940Medicare ID - Type Unspecified