Provider Demographics
NPI:1871091306
Name:CROCKETT, MELISSA MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11939 RIVER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-1354
Mailing Address - Country:US
Mailing Address - Phone:952-890-4480
Mailing Address - Fax:
Practice Address - Street 1:11939 RIVER HILLS DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-1354
Practice Address - Country:US
Practice Address - Phone:952-890-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN731078164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse