Provider Demographics
NPI:1417060781
Name:MCCRACKIN, MARY WYNETTE (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:WYNETTE
Last Name:MCCRACKIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:WYNETTE
Other - Middle Name:R
Other - Last Name:REVELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:1300 ATLANTIC BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32233
Practice Address - Country:US
Practice Address - Phone:904-221-0264
Practice Address - Fax:904-390-7507
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3025322363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018341300Medicaid
FLU6652ZMedicare PIN
FL018341300Medicaid