Basic Information
| Provider Information | |||||||||
| NPI: | 1679720775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 DATAPOINT DR | ||||||||
| Address2: | STE 865 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782295900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102936006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8401 DATAPOINT DR | ||||||||
| Address2: | STE 865 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102936006 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2008 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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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 | 568353 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 568353 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.