Provider Demographics
NPI:1760835961
Name:MCCRACKEN, MOLLY MINNIX (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:MINNIX
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7605 FOREST AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4940
Mailing Address - Country:US
Mailing Address - Phone:804-289-4941
Mailing Address - Fax:
Practice Address - Street 1:7605 FOREST AVE STE 303
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4940
Practice Address - Country:US
Practice Address - Phone:804-289-4941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173693363LG0600X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1760835961Medicaid