Healthcare Provider Details

I. General information

NPI: 1265341655
Provider Name (Legal Business Name): HEATHER MARIE EVELYN CROCKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CHATEAU DR SE APT I4
ROME GA
30161-6664
US

IV. Provider business mailing address

50 CHATEAU DR SE APT I4
ROME GA
30161-6664
US

V. Phone/Fax

Practice location:
  • Phone: 770-864-4198
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN300735
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: