Provider Demographics
NPI:1083044010
Name:MCCRAE, TINA (RN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MCCRAE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3971
Mailing Address - Country:US
Mailing Address - Phone:509-526-1763
Mailing Address - Fax:509-522-4480
Practice Address - Street 1:1150 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3971
Practice Address - Country:US
Practice Address - Phone:509-526-1763
Practice Address - Fax:509-522-4480
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN 60238314390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN 60238314OtherRN