Provider Demographics
NPI:1124283999
Name:CRADDOCK, ALICIA M (CRNA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:M
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:M
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2540 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8605
Mailing Address - Country:US
Mailing Address - Phone:770-644-1274
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:770-644-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000154198163W00000X
GARN168147163W00000X, 367500000X
TNAPN0000013603367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP00770314OtherRAILROAD MEDICARE
GAN480408OtherWELLCARE (GA MEDICAID)
NC8053486Medicaid
AL108083Medicaid
GA662969153AMedicaid
TN4157214OtherBLUE CROSS BLUE SHIELD TN
TN1510651Medicaid
TN4157214OtherBLUE CROSS BLUE SHIELD TN