Provider Demographics
NPI:1639164759
Name:CROCKER, SHIRLEEN (LD)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEEN
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:LD
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 409
Mailing Address - Street 2:
Mailing Address - City:MARSHALLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31057-0409
Mailing Address - Country:US
Mailing Address - Phone:478-967-2195
Mailing Address - Fax:706-647-3372
Practice Address - Street 1:314 E LEE ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-4122
Practice Address - Country:US
Practice Address - Phone:706-647-7148
Practice Address - Fax:706-647-3372
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001487133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education