Basic Information
| Provider Information | |||||||||
| NPI: | 1710483771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAGETT- KNOWLES | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAGETT | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1396 WHISPER CIR | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338701204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633851244 | ||||||||
| FaxNumber: | 8633856086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2018 | ||||||||
| LastUpdateDate: | 04/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN9212525 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 108840200 | 05 | FL | MEDICAID |