Provider Demographics
NPI:1780323451
Name:CRAVEN, NICOLE MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:CRAVEN
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 1:1325 PENNSYLVANIA AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2133
Practice Address - Country:US
Practice Address - Phone:817-502-9918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX771138163WN0002X
TX1091400363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care