Provider Demographics
NPI:1659714061
Name:CRADDOCK, RACHEL ANNE (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 RAVENSHILL WAY
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7737
Mailing Address - Country:US
Mailing Address - Phone:214-649-7255
Mailing Address - Fax:386-822-7809
Practice Address - Street 1:421 N WOODLAND BLVD
Practice Address - Street 2:UNIT 8317
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-8300
Practice Address - Country:US
Practice Address - Phone:386-822-7152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 28432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer