Provider Demographics
NPI:1629966767
Name:CRAWFORD, NICHELLE
Entity type:Individual
Prefix:
First Name:NICHELLE
Middle Name:
Last Name:CRAWFORD
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 1:2621 GREEN RIVER ROAD
Mailing Address - Street 2:#105-2106
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-7454
Mailing Address - Country:US
Mailing Address - Phone:951-264-0901
Mailing Address - Fax:
Practice Address - Street 1:2621 GREEN RIVER ROAD
Practice Address - Street 2:#105-2106
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-7454
Practice Address - Country:US
Practice Address - Phone:951-264-0901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-26
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier