Provider Demographics
NPI:1841629409
Name:CROCKETT, KRISTINE MORIN (FNP-BC)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MORIN
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-2737
Mailing Address - Country:US
Mailing Address - Phone:617-740-0207
Mailing Address - Fax:
Practice Address - Street 1:425 HARVARD ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-2737
Practice Address - Country:US
Practice Address - Phone:617-740-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2281190363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily