Provider Demographics
NPI:1467478867
Name:CROCKFORD, CARLA JEANNE (ARNP/PMHNP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:JEANNE
Last Name:CROCKFORD
Suffix:
Gender:F
Credentials:ARNP/PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661
Mailing Address - Country:US
Mailing Address - Phone:360-695-1014
Mailing Address - Fax:360-750-1374
Practice Address - Street 1:1014 MAIN STREET
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-695-1014
Practice Address - Fax:360-750-1374
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450092NP PMHNP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR831447012OtherBLUE CROSS BLUE SHIELD
ORR130494Medicare ID - Type Unspecified
ORQ09217Medicare UPIN