Provider Demographics
NPI:1730517186
Name:CRANDALL, JOHN (BA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13602 E 85TH ST N APT 103
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-8612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13602 E 85TH ST N APT 103
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8612
Practice Address - Country:US
Practice Address - Phone:417-315-7962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator