Provider Demographics
NPI:1043518723
Name:CROCKER, WANDA SHIRL (LPN)
Entity Type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:SHIRL
Last Name:CROCKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 DECATUR CT
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-3114
Mailing Address - Country:US
Mailing Address - Phone:513-324-1486
Mailing Address - Fax:
Practice Address - Street 1:722 DECATUR CT
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-3114
Practice Address - Country:US
Practice Address - Phone:513-324-1486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-131163-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse