Provider Demographics
NPI:1912213653
Name:CRAIG, MICA LATICE (LPN)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:LATICE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 PARKCREST DR SW
Mailing Address - Street 2:APT 9
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9330
Mailing Address - Country:US
Mailing Address - Phone:616-634-4903
Mailing Address - Fax:
Practice Address - Street 1:1921 PARKCREST DR SW
Practice Address - Street 2:APT 9
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9330
Practice Address - Country:US
Practice Address - Phone:616-634-4903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703094690164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse