Provider Demographics
NPI:1386616837
Name:CROCKETT, LINDA WINSTON (ARNP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:WINSTON
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:DAVISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7041 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7220
Mailing Address - Country:US
Mailing Address - Phone:253-474-2120
Mailing Address - Fax:
Practice Address - Street 1:7041 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7220
Practice Address - Country:US
Practice Address - Phone:253-474-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP560A363LF0000X
WAAP30006591363L00000X, 363LF0000X, 363LP2300X, 363LP0200X, 363LS0200X, 363LX0106X
WAAP3006591363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806304700Medicaid
ID806304700Medicaid