Provider Demographics
NPI:1699757104
Name:MCCRACKEN, BONNIE FRANCES (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:FRANCES
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 MISTY WOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7911
Mailing Address - Country:US
Mailing Address - Phone:916-734-5590
Mailing Address - Fax:916-734-0907
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:RM 4212
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-5590
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4953363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20811ZMedicare ID - Type Unspecified