Provider Demographics
NPI:1558650515
Name:CROCKETT, STEFANIE GAYLE (MSN, RN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:GAYLE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MSN, RN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 S COULTER ST STE 300
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1766
Mailing Address - Country:US
Mailing Address - Phone:806-355-6330
Mailing Address - Fax:806-351-0950
Practice Address - Street 1:1301 S COULTER ST STE 300
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1766
Practice Address - Country:US
Practice Address - Phone:806-355-6330
Practice Address - Fax:806-351-0950
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP120155363LF0000X
TX730571163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX730571OtherNURSE PRACTITIONER-FAMILY NURSE PRACTITIONER