Provider Demographics
NPI:1518601889
Name:MCCRACKEN, JOHANNA LEE
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:LEE
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 MARIPOSA ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6846
Mailing Address - Country:US
Mailing Address - Phone:904-814-0765
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1096
Practice Address - Country:US
Practice Address - Phone:305-585-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program