Provider Demographics
NPI:1336799956
Name:CROCKETT, KAMILLE BOSTON (FNP)
Entity type:Individual
Prefix:
First Name:KAMILLE
Middle Name:BOSTON
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1731 W BRIDGE POINTE WAY
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5040
Mailing Address - Country:US
Mailing Address - Phone:702-994-0598
Mailing Address - Fax:
Practice Address - Street 1:757 W TELEGRAPH ST STE 125
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-1533
Practice Address - Country:US
Practice Address - Phone:702-994-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8059814-3102163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory