Healthcare Provider Details

I. General information

NPI: 1174411219
Provider Name (Legal Business Name): DONNA CROCKETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 N EAGLE CREEK DR STE 302
LEXINGTON KY
40509-2124
US

IV. Provider business mailing address

PO BOX 936
LONDON KY
40743-0936
US

V. Phone/Fax

Practice location:
  • Phone: 859-967-5044
  • Fax: 859-967-5041
Mailing address:
  • Phone: 606-330-7835
  • Fax: 859-967-5041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4042815
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number4042815
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: