Provider Demographics
NPI:1023392867
Name:CRNKOVIC, KIMBERLY N (PD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:CRNKOVIC
Suffix:
Gender:F
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6862 OLD MONROE RD
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5682
Mailing Address - Country:US
Mailing Address - Phone:318-281-7020
Mailing Address - Fax:
Practice Address - Street 1:2211 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4072
Practice Address - Country:US
Practice Address - Phone:318-281-3284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14581183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist