Provider Demographics
NPI:1215443692
Name:MCCRACKEN, MARY KATHLEEN (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N. FIFTH STREET
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MARTINS FERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43935
Mailing Address - Country:US
Mailing Address - Phone:740-232-6104
Mailing Address - Fax:740-609-3483
Practice Address - Street 1:222 N. FIFTH STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935
Practice Address - Country:US
Practice Address - Phone:740-232-6104
Practice Address - Fax:740-609-3483
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2017022598363L00000X
OHAPRN.CNP.021969363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0275191Medicaid