Provider Demographics
NPI:1114401247
Name:CROCKETT, KORAH (LVN)
Entity Type:Individual
Prefix:
First Name:KORAH
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 STATE HIGHWAY 198 APT 127
Mailing Address - Street 2:
Mailing Address - City:MALAKOFF
Mailing Address - State:TX
Mailing Address - Zip Code:75148-4988
Mailing Address - Country:US
Mailing Address - Phone:903-519-4663
Mailing Address - Fax:
Practice Address - Street 1:3801 STATE HIGHWAY 198 APT 127
Practice Address - Street 2:
Practice Address - City:MALAKOFF
Practice Address - State:TX
Practice Address - Zip Code:75148-4988
Practice Address - Country:US
Practice Address - Phone:903-519-4663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345233164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse