Provider Demographics
NPI:1740564954
Name:CROCKETT, TANYA EZELL (APRN, CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:EZELL
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 BRASHER ST
Mailing Address - Street 2:
Mailing Address - City:WILMORE
Mailing Address - State:KY
Mailing Address - Zip Code:40390-1059
Mailing Address - Country:US
Mailing Address - Phone:859-858-9154
Mailing Address - Fax:
Practice Address - Street 1:496 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1827
Practice Address - Country:US
Practice Address - Phone:859-288-2425
Practice Address - Fax:859-721-3918
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007181363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100197040Medicaid
KY7100197040Medicaid