Provider Demographics
NPI:1417060781
Name:MCCRACKIN, MARY WYNETTE (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WYNETTE
Last Name:MCCRACKIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:WYNETTE
Other - Middle Name:R
Other - Last Name:REVELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6555 CHESTER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2279
Mailing Address - Country:US
Mailing Address - Phone:904-265-8209
Mailing Address - Fax:904-503-3577
Practice Address - Street 1:6555 CHESTER AVE STE 1
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2279
Practice Address - Country:US
Practice Address - Phone:904-265-8209
Practice Address - Fax:904-503-3577
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3025322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018341300Medicaid
FLU6652ZMedicare PIN
FL018341300Medicaid