Provider Demographics
NPI:1659461374
Name:CROCKER, ROSALYN E (RN)
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:E
Last Name:CROCKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 SW ERICKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3849
Mailing Address - Country:US
Mailing Address - Phone:503-641-5280
Mailing Address - Fax:
Practice Address - Street 1:5350 SW ERICKSON AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3849
Practice Address - Country:US
Practice Address - Phone:503-641-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080045436RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098900Medicaid