Basic Information
| Provider Information | |||||||||
| NPI: | 1851685259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROFTS | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526677 | ||||||||
| FaxNumber: | 3073526614 | ||||||||
| Practice Location | |||||||||
| Address1: | 2706 ANKENY WAY | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073526689 | ||||||||
| FaxNumber: | 3073526614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2011 | ||||||||
| LastUpdateDate: | 06/02/2011 | ||||||||
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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 | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.