MEDICARE: DANIELLE CROCKETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1528416971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE CROCKETT

Provider Business Mailing Address
First Line	:	1935 E 28TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2532
Country	:	US
Telephone Number	:	646-812-2671
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 E 28TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2532
Country	:	US
Telephone Number	:	646-812-2671
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	05/26/2016

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Directions to “ DANIELLE CROCKETT ” Practice Location

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