Provider Demographics
NPI:1528597341
Name:CRAVEN, CARLIE ANN
Entity Type:Individual
Prefix:MISS
First Name:CARLIE
Middle Name:ANN
Last Name:CRAVEN
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 1:1032 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2913
Mailing Address - Country:US
Mailing Address - Phone:570-558-8660
Mailing Address - Fax:570-558-6147
Practice Address - Street 1:1032 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18509-2913
Practice Address - Country:US
Practice Address - Phone:570-558-8660
Practice Address - Fax:570-558-6147
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059374363A00000X
PAOA004282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant