Provider Demographics
NPI:1750978144
Name:KRACUS, AMBERLY
Entity type:Individual
Prefix:
First Name:AMBERLY
Middle Name:
Last Name:KRACUS
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 1:2123 REVERE AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1817
Mailing Address - Country:US
Mailing Address - Phone:937-478-5056
Mailing Address - Fax:
Practice Address - Street 1:2123 REVERE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1817
Practice Address - Country:US
Practice Address - Phone:937-478-5056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2221965Medicaid