Provider Demographics
NPI:1164860383
Name:KRALICEK, CARRIE ANN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:KRALICEK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1633
Mailing Address - Country:US
Mailing Address - Phone:541-808-9599
Mailing Address - Fax:541-808-9559
Practice Address - Street 1:153 N BROADWAY
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1633
Practice Address - Country:US
Practice Address - Phone:541-808-9599
Practice Address - Fax:541-808-9559
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIP60386649363LF0000X
OR201401811NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily