Provider Demographics
NPI:1316379431
Name:KRACKER, STEPHANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:KRACKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 DAMASCUS RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-5535
Mailing Address - Country:US
Mailing Address - Phone:937-578-2626
Mailing Address - Fax:937-578-2627
Practice Address - Street 1:388 DAMASCUS RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-5535
Practice Address - Country:US
Practice Address - Phone:937-578-2626
Practice Address - Fax:937-578-2627
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant