Provider Demographics
NPI:1447561600
Name:MCCRACKEN, KELSEY MANDELL (NP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MANDELL
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:S40
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-445-7857
Mailing Address - Fax:216-636-5406
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:S40
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-445-7857
Practice Address - Fax:216-636-5406
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008122363L00000X
IAA-130733363L00000X
OH18691363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1447561600Medicaid
IA421417307-VQOtherUHC-RV
IA1447561600Medicaid