Provider Demographics
NPI:1891785523
Name:CROCKER, LERRYN U (ADN BSN MSN FNP)
Entity Type:Individual
Prefix:
First Name:LERRYN
Middle Name:U
Last Name:CROCKER
Suffix:
Gender:F
Credentials:ADN BSN MSN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 THURMOND TANNER RD
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542
Mailing Address - Country:US
Mailing Address - Phone:678-513-5733
Mailing Address - Fax:678-513-5836
Practice Address - Street 1:25 HOSPITAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-2738
Practice Address - Country:US
Practice Address - Phone:843-784-8224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN059534 CNS/PMH NP363LF0000X, 363LP0808X
SC22182363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000970109AMedicaid
GA00970109AMedicaid
GAP58921Medicare UPIN