Provider Demographics
NPI:1487213930
Name:CROCKETT, RHONDA A
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:A
Last Name:CROCKETT
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 1:120 WYONIA WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-2421
Mailing Address - Country:US
Mailing Address - Phone:404-719-9549
Mailing Address - Fax:866-341-3403
Practice Address - Street 1:401 WESTPARK CT STE 200
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3572
Practice Address - Country:US
Practice Address - Phone:800-341-0120
Practice Address - Fax:866-341-3403
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-09
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000111222333OtherCERTIFIED PEER SPECIALIST
GA000111222333444OtherHOME HEALTH CARE PROVIDER
MI8087075Medicaid