Basic Information
| Provider Information | |||||||||
| NPI: | 1497245419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | IYAHNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 MURFREESBORO PIKE STE 702 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372172679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157244722 | ||||||||
| FaxNumber: | 8039054431 | ||||||||
| Practice Location | |||||||||
| Address1: | 2460 INDIA HOOK RD STE AND105 | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297323530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033666250 | ||||||||
| FaxNumber: | 8033666261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 17-44081 | SC | Y |
No ID Information.