Provider Demographics
NPI:1144769613
Name:CROCKER, CHARLAINE ANN (RNFA)
Entity Type:Individual
Prefix:MS
First Name:CHARLAINE
Middle Name:ANN
Last Name:CROCKER
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3405 VISTA LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5835
Mailing Address - Country:US
Mailing Address - Phone:817-239-6330
Mailing Address - Fax:
Practice Address - Street 1:3405 VISTA LAKE CIR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5835
Practice Address - Country:US
Practice Address - Phone:817-239-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX443263163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant