Basic Information
| Provider Information | |||||||||
| NPI: | 1962826123 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAFT | ||||||||
| FirstName: | TONYA | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | RRT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 PARK CIRCLE DR APT D46 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392327633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018629111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E WOODROW WILSON AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013624471 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2014 | ||||||||
| LastUpdateDate: | 02/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 227900000X | RCP2815 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |
ID Information
| ID | Type | State | Issuer | Description | 286500000 | 05 | MS | MEDICAID |