Basic Information
| Provider Information | |||||||||
| NPI: | 1154712941 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRADDOCK | ||||||||
| FirstName: | MARGARET | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 345 CLYDE MORRIS BLVD STE 490 | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321743114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866723933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2015 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP 9265443 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | ARNP9265443 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 110834400 | 05 | FL | MEDICAID |