Provider Demographics
NPI:1578861779
Name:CROCKER, MELISSA DAWN (CPNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:CROCKER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99371
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0371
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-7347
Practice Address - Street 1:701 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9164
Practice Address - Country:US
Practice Address - Phone:817-453-5437
Practice Address - Fax:817-453-2714
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX712934363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219895401Medicaid
TX219895402OtherCSHCN
TX219895401Medicaid