Provider Demographics
NPI:1891232757
Name:CROCKETT, TIMIKA ROSHAUN (NP)
Entity Type:Individual
Prefix:
First Name:TIMIKA
Middle Name:ROSHAUN
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:BELZONI
Mailing Address - State:MS
Mailing Address - Zip Code:39038-4031
Mailing Address - Country:US
Mailing Address - Phone:601-750-5153
Mailing Address - Fax:
Practice Address - Street 1:6501 DOGWOOD VIEW PKWY STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7857
Practice Address - Country:US
Practice Address - Phone:601-899-3340
Practice Address - Fax:601-899-3343
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily