Provider Demographics
NPI:1952566440
Name:CROCKETT, BRIDGET R (ANP)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:R
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 BRANTLEY RD
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-8315
Mailing Address - Country:US
Mailing Address - Phone:501-268-6102
Mailing Address - Fax:501-268-4445
Practice Address - Street 1:112 BRANTLY ROAD
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-6113
Practice Address - Country:US
Practice Address - Phone:501-268-6102
Practice Address - Fax:501-268-4445
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP-000160363L00000X
ARA03144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR176018758Medicaid
AR57297Medicare PIN
AR176018758Medicaid