Provider Demographics
NPI:1013182112
Name:CRADDOCK, MICHELLE MARILYN (ANP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARILYN
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 BELLE TERRE RD
Mailing Address - Street 2:SUITE 119 PORT JEFFERSON MED ASSOC
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-642-0609
Mailing Address - Fax:631-642-0588
Practice Address - Street 1:625 BELLE TERRE RD
Practice Address - Street 2:SUITE 119 PORT JEFFERSON MEDICAL ASSOC
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-642-0609
Practice Address - Fax:631-642-0588
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3325721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine