Provider Demographics
NPI:1114632197
Name:KROCKEY, ISABELLA
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:
Last Name:KROCKEY
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 1:16342 W LANFEAR DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16342 W LANFEAR DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-4747
Practice Address - Country:US
Practice Address - Phone:815-905-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.007127390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program