Provider Demographics
NPI:1780287805
Name:CRAYCRAFT, DEBORAH L
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:CRAYCRAFT
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 1:11158 MARTIN ALEXANDER RD
Mailing Address - Street 2:
Mailing Address - City:SARDINIA
Mailing Address - State:OH
Mailing Address - Zip Code:45171-9239
Mailing Address - Country:US
Mailing Address - Phone:937-515-1956
Mailing Address - Fax:
Practice Address - Street 1:11158 MARTIN ALEXANDER RD
Practice Address - Street 2:
Practice Address - City:SARDINIA
Practice Address - State:OH
Practice Address - Zip Code:45171-9239
Practice Address - Country:US
Practice Address - Phone:937-515-1956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0801627Medicaid