Basic Information
| Provider Information | |||||||||
| NPI: | 1538354733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | ALECIA | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1300 | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712951300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184359411 | ||||||||
| FaxNumber: | 2257659244 | ||||||||
| Practice Location | |||||||||
| Address1: | 2104 LOOP RD STE C | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712953341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184354571 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP05271 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1143235 | 05 | LA | MEDICAID | 3C893 | 01 | LA | MEDICARE | OTHER | 12494267 | 01 | CAQH | OTHER | P02474561 | 01 | LA | RR MEDICARE | OTHER |