1124538533 NPI number — MRS. LYNNE CROCKETT CHARLES PT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124538533 NPI number — MRS. LYNNE CROCKETT CHARLES PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLES
Provider First Name:
LYNNE
Provider Middle Name:
CROCKETT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROCKETT
Provider Other First Name:
FRANCES
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124538533
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1932 GULLWING DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKWALL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75087-5389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-509-8994
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 E RALPH HALL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKWALL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75032-6878
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-722-0555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1286062 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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