Provider Demographics
NPI:1699594374
Name:CROCKETT, CANDY MILLER (BSN, RN)
Entity type:Individual
Prefix:
First Name:CANDY
Middle Name:MILLER
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 E MEDICAL TOWER DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4872
Mailing Address - Country:US
Mailing Address - Phone:801-314-4500
Mailing Address - Fax:801-314-2909
Practice Address - Street 1:181 E MEDICAL TOWER DR
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4872
Practice Address - Country:US
Practice Address - Phone:801-314-4500
Practice Address - Fax:801-314-2909
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7036504-3102163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator