| NPI | 1962611129 |
|---|---|
| Former Name | CRYSTAL J HEACOCK |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 202100029NP-PP) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: IA 109002) |
| 363LF0000X Nurse Practitioner, Family (Licence: IA A156728) | |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2021-01-29 |