Provider Demographics
NPI:1265480065
Name:CROCKFORD, NICOLE LYNNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNNE
Last Name:CROCKFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:603 ADDLESTONE WAY
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-8963
Mailing Address - Country:US
Mailing Address - Phone:864-415-5025
Mailing Address - Fax:864-583-9360
Practice Address - Street 1:2030 NORTH CHURCH PLACE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-582-6858
Practice Address - Fax:864-583-9360
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant