Provider Demographics
NPI:1699220079
Name:CRUTCHER, JILL (ARNP)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:CRUTCHER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 E WASHINGTON ST
Mailing Address - Street 2:UNIT 609
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3706
Mailing Address - Country:US
Mailing Address - Phone:310-721-4523
Mailing Address - Fax:
Practice Address - Street 1:5950 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2532
Practice Address - Country:US
Practice Address - Phone:863-688-3550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-16
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001137363LP0200X
FL9437093363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics