Basic Information
| Provider Information | |||||||||
| NPI: | 1013464411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCRACKEN | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 81 LAKE AVENUE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686901 | ||||||||
| FaxNumber: | 5855465806 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 LAKE AVENUE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686901 | ||||||||
| FaxNumber: | 5855465806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2016 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA0400X | 554297 | NY | Y | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) |
No ID Information.