Healthcare Provider Details

I. General information

NPI: 1336799956
Provider Name (Legal Business Name): KAMILLE BOSTON CROCKETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 W TELEGRAPH ST STE 125
WASHINGTON UT
84780-1533
US

IV. Provider business mailing address

1731 W BRIDGE POINTE WAY
ST GEORGE UT
84770-5040
US

V. Phone/Fax

Practice location:
  • Phone: 702-994-0598
  • Fax:
Mailing address:
  • Phone: 702-994-0598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number8059814-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: