Provider Demographics
NPI:1982742813
Name:CREDO, JIMMY (RRT-NPS, RPFT)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:CREDO
Suffix:
Gender:M
Credentials:RRT-NPS, RPFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 N STEVES BLVD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-6842
Mailing Address - Country:US
Mailing Address - Phone:928-714-0746
Mailing Address - Fax:
Practice Address - Street 1:167 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54092279P1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279P1006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredPulmonary Function Technologist