Provider Demographics
NPI:1366912511
Name:CROCKER, BEVERLY
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BEVERLY
Other - Middle Name:
Other - Last Name:CROCKER-JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:17955 NW 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3807
Mailing Address - Country:US
Mailing Address - Phone:305-978-1474
Mailing Address - Fax:305-754-2176
Practice Address - Street 1:17955 NW 18TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-3807
Practice Address - Country:US
Practice Address - Phone:305-978-1474
Practice Address - Fax:305-754-2176
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant