Provider Demographics
NPI:1184813065
Name:CRADDOCK, CARRIE L (LAC)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 SUNBURY RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-9795
Mailing Address - Country:US
Mailing Address - Phone:740-816-2571
Mailing Address - Fax:740-362-1293
Practice Address - Street 1:593 SUNBURY RD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-9795
Practice Address - Country:US
Practice Address - Phone:740-816-2571
Practice Address - Fax:740-362-1293
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH 103171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist