Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 11395933-4810 | UT |
Y | 213ES0000X | Sports Medicine | 11395933-4810 | UT |
NPI | 1396393393 |
---|---|
Provider Name | Camille Elizabeth Crockett |
First Address | Provo, UT 84602-2246 |
Second Address | Provo, UT 84602-2246 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2019 |
Last Update Date | 03/09/2019 |