Basic Information
| Provider Information | |||||||||
| NPI: | 1366548430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | SHELLI | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 172 LINDEN DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226012892 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766798890 | ||||||||
| FaxNumber: | 2766799740 | ||||||||
| Practice Location | |||||||||
| Address1: | 96 15TH ST NW | ||||||||
| Address2: | 104 | ||||||||
| City: | NORTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242731620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766798890 | ||||||||
| FaxNumber: | 2766799740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024164715 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.