Provider Demographics
NPI:1730148461
Name:CROLLARD, GERALD THOMAS (RN)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:THOMAS
Last Name:CROLLARD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:THOMAS
Other - Last Name:CROLLARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:11050 CAMINO PLAYA CARMEL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-4141
Mailing Address - Country:US
Mailing Address - Phone:858-427-6683
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL CAMP PENDLETON
Practice Address - Street 2:BOX 555191
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5191
Practice Address - Country:US
Practice Address - Phone:760-725-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA521295163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical