Provider Demographics
NPI:1740429943
Name:CROCKER, CYNTHIA L (OTR)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:L
Last Name:CROCKER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 FIANNA WAY # MD3881
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72919-9008
Mailing Address - Country:US
Mailing Address - Phone:205-335-4374
Mailing Address - Fax:
Practice Address - Street 1:1000 FIANNA WAY # MD3881
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72919-9008
Practice Address - Country:US
Practice Address - Phone:205-335-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0425172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker