Provider Demographics
NPI:1811467012
Name:CROCKETT, REGINA
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CROCKETT
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 1:601 N MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-1455
Mailing Address - Country:US
Mailing Address - Phone:757-803-4702
Mailing Address - Fax:757-562-1612
Practice Address - Street 1:601 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-1455
Practice Address - Country:US
Practice Address - Phone:757-803-4702
Practice Address - Fax:757-562-1612
Is Sole Proprietor?:No
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide