Provider Demographics
NPI:1710104500
Name:CRAIG, SUSAN (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:CRAIG
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:CULLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:900 W MAGNOLIA AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-8518
Mailing Address - Country:US
Mailing Address - Phone:817-921-6166
Mailing Address - Fax:
Practice Address - Street 1:900 W MAGNOLIA AVE STE 201
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8518
Practice Address - Country:US
Practice Address - Phone:817-921-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX238366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0851099-02OtherISSUER
TXTPI 1427593-02Medicaid
TX0851099-02OtherISSUER