Provider Demographics
NPI:1649636853
Name:CROCKER, CORTNEY (CPNP-PC)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:
Other - Last Name:SHUMWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 W GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1631
Mailing Address - Country:US
Mailing Address - Phone:231-547-6523
Mailing Address - Fax:231-547-6238
Practice Address - Street 1:205 GROVE ST
Practice Address - Street 2:
Practice Address - City:MANCELONA
Practice Address - State:MI
Practice Address - Zip Code:49659-8018
Practice Address - Country:US
Practice Address - Phone:231-587-9840
Practice Address - Fax:231-587-9846
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2529363LP0200X
MO2015039036363LP0200X
MI4704271709363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics