Healthcare Provider Details

I. General information

NPI: 1801883475
Provider Name (Legal Business Name): ROBERT DAVID CROCKETT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N COLLEGE AVE
FAYETTEVILLE AR
72703-1944
US

IV. Provider business mailing address

2828 N NATIONAL AVE
SPRINGFIELD MO
65803-4306
US

V. Phone/Fax

Practice location:
  • Phone: 615-355-3451
  • Fax:
Mailing address:
  • Phone: 417-837-4000
  • Fax: 417-875-4714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2000160927
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2000160927
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: