Basic Information
| Provider Information | |||||||||
| NPI: | 1013281427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRULL | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294414 | ||||||||
| Practice Location | |||||||||
| Address1: | 2115 S FREMONT AVE | ||||||||
| Address2: | STE 3300 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658042239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178205200 | ||||||||
| FaxNumber: | 4178205220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 07/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 2011040496 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 10132814257 | 05 | MO | MEDICAID | 191534758 | 05 | AR | MEDICAID | P01036357 | 01 | MO | RR MCR | OTHER | 431560263 | 01 | MO | TRICARE | OTHER |