Provider Demographics
NPI:1457749137
Name:CROCKETT, STEPHEN A
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9932 GREENRIVER DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-2012
Mailing Address - Country:US
Mailing Address - Phone:513-518-9028
Mailing Address - Fax:
Practice Address - Street 1:9932 GREENRIVER DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45231-2012
Practice Address - Country:US
Practice Address - Phone:513-518-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH133319164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse