Healthcare Provider Details

I. General information

NPI: 1154347359
Provider Name (Legal Business Name): DELLA D CROFT PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E 1ST ST
DIXON IL
61021
US

IV. Provider business mailing address

403 E 1ST ST
DIXON IL
61021-3116
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5629
  • Fax: 815-285-5634
Mailing address:
  • Phone: 815-285-5629
  • Fax: 815-285-5634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA312
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085000762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: