Provider Demographics
NPI:1609821743
Name:CRADDOCK, ALISA (WHC-NP)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:WHC-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79101-4307
Mailing Address - Country:US
Mailing Address - Phone:806-372-8731
Mailing Address - Fax:806-372-8746
Practice Address - Street 1:1501 S TAYLOR ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79101-4307
Practice Address - Country:US
Practice Address - Phone:806-372-8731
Practice Address - Fax:806-372-8746
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX516437363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153890-20Medicaid