Healthcare Provider Details

I. General information

NPI: 1356501423
Provider Name (Legal Business Name): VIRGINIA CROCKER GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 COMMERCE ST
POWELLSVILLE NC
27967
US

IV. Provider business mailing address

PO BOX 40
POWELLSVILLE NC
27967-0040
US

V. Phone/Fax

Practice location:
  • Phone: 252-332-6484
  • Fax:
Mailing address:
  • Phone: 252-332-6484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number600104
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: