Provider Demographics
NPI:1104364744
Name:CROUCH, CHONG AE (NP/RXN/RN)
Entity Type:Individual
Prefix:MRS
First Name:CHONG
Middle Name:AE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:NP/RXN/RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 RUSKIN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-2522
Mailing Address - Country:US
Mailing Address - Phone:719-572-6100
Mailing Address - Fax:
Practice Address - Street 1:115 S PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80910-3130
Practice Address - Country:US
Practice Address - Phone:719-572-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-02
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN. 1631584163W00000X
COAPN.0992942-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse