Healthcare Provider Details

I. General information

NPI: 1396393393
Provider Name (Legal Business Name): CAMILLE ELIZABETH CROCKETT ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1130 SMITH FIELDHOUSE
PROVO UT
84602-2246
US

IV. Provider business mailing address

1130 SMITH FIELDHOUSE
PROVO UT
84602-2246
US

V. Phone/Fax

Practice location:
  • Phone: 801-422-2946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number11395933-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: