Provider Demographics
NPI:1518360221
Name:CRAVENS, AUDREY (CNM)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:CRAVENS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-4002
Mailing Address - Country:US
Mailing Address - Phone:914-699-7200
Mailing Address - Fax:914-699-0837
Practice Address - Street 1:30 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-3712
Practice Address - Country:US
Practice Address - Phone:914-968-4898
Practice Address - Fax:914-968-5496
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001640367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04016097Medicaid