Provider Demographics
NPI:1790253466
Name:CROCHRELL, DEWANDA
Entity Type:Individual
Prefix:MS
First Name:DEWANDA
Middle Name:
Last Name:CROCHRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IL
Mailing Address - Zip Code:62060-1236
Mailing Address - Country:US
Mailing Address - Phone:618-334-1181
Mailing Address - Fax:
Practice Address - Street 1:2116 EDISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4717
Practice Address - Country:US
Practice Address - Phone:618-334-1181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty