Provider Demographics
NPI:1619371614
Name:PICKETT-CROCKETT, SHJUAN D
Entity Type:Individual
Prefix:
First Name:SHJUAN
Middle Name:D
Last Name:PICKETT-CROCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHJUAN
Other - Middle Name:D
Other - Last Name:PICKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:1768 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AL
Mailing Address - Zip Code:36756-3406
Mailing Address - Country:US
Mailing Address - Phone:334-682-9086
Mailing Address - Fax:334-682-9082
Practice Address - Street 1:1768 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AL
Practice Address - Zip Code:36756-3406
Practice Address - Country:US
Practice Address - Phone:334-682-9085
Practice Address - Fax:334-682-9082
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-113983363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily