Provider Demographics
NPI:1790057925
Name:CRADDOCK, KELLY-ANN P
Entity Type:Individual
Prefix:
First Name:KELLY-ANN
Middle Name:P
Last Name:CRADDOCK
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 1:260 E 161ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3512
Mailing Address - Country:US
Mailing Address - Phone:718-993-3397
Mailing Address - Fax:
Practice Address - Street 1:260 E 161ST ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3512
Practice Address - Country:US
Practice Address - Phone:718-993-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286516-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse