Provider Demographics
NPI:1083128748
Name:COCKRELL, RACHELLE
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:COCKRELL
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 1:19214 BUCKBOARD CIR
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-7263
Mailing Address - Country:US
Mailing Address - Phone:605-210-2113
Mailing Address - Fax:
Practice Address - Street 1:1420 N 10TH ST
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-1532
Practice Address - Country:US
Practice Address - Phone:605-717-8595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP00130363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily