Provider Demographics
NPI:1124263850
Name:MCCRACKEN, AMANDA (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 MONTAUK CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7828
Mailing Address - Country:US
Mailing Address - Phone:503-470-9161
Mailing Address - Fax:
Practice Address - Street 1:7045 MONTAUK CIR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7828
Practice Address - Country:US
Practice Address - Phone:503-470-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10973247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other