Provider Demographics
NPI:1942410733
Name:MCCRACKEN-BENNETT, ASHLEY ROSE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ROSE
Last Name:MCCRACKEN-BENNETT
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 1:9019 JOHNSTOWN ALEXANDRIA RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43031-8133
Mailing Address - Country:US
Mailing Address - Phone:740-967-1177
Mailing Address - Fax:
Practice Address - Street 1:9019 JOHNSTOWN ALEXANDRIA RD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:OH
Practice Address - Zip Code:43031-8133
Practice Address - Country:US
Practice Address - Phone:740-967-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4502729Medicaid