Provider Demographics
NPI:1710793278
Name:CROOM, OPAL WENDY (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:OPAL
Middle Name:WENDY
Last Name:CROOM
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3656 TIERRA LISBOA LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-4317
Mailing Address - Country:US
Mailing Address - Phone:206-718-5047
Mailing Address - Fax:915-742-3098
Practice Address - Street 1:21227 TORCH ROAD
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79901
Practice Address - Country:US
Practice Address - Phone:915-742-7263
Practice Address - Fax:915-742-3098
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX690310163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management