Provider Demographics
NPI:1316101082
Name:KRACKENBERGER, DENISE KATHRYN (ACNP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:KATHRYN
Last Name:KRACKENBERGER
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:KATHRYN
Other - Last Name:ANTONOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE UNIT 406
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6258
Practice Address - Country:US
Practice Address - Phone:503-435-1200
Practice Address - Fax:503-434-9572
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014649363LA2100X
GARN151196363LA2100X
OR201801073NP-PP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care