Provider Demographics
NPI:1912974049
Name:CROCKER, MELANI ANN (DC)
Entity type:Individual
Prefix:DR
First Name:MELANI
Middle Name:ANN
Last Name:CROCKER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 N JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:MO
Mailing Address - Zip Code:65536-2745
Mailing Address - Country:US
Mailing Address - Phone:417-532-2986
Mailing Address - Fax:417-532-2271
Practice Address - Street 1:617 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-2745
Practice Address - Country:US
Practice Address - Phone:417-532-2986
Practice Address - Fax:417-532-2271
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005229111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00032217Medicare ID - Type Unspecified