Basic Information
| Provider Information | |||||||||
| NPI: | 1285747493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | JENELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CFNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ABBOTT | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | JENELL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093278 | ||||||||
| FaxNumber: | 7065094600 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 TURNER MCCALL BLVD | ||||||||
| Address2: | THE BREAST CENTER | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301650233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065096852 | ||||||||
| FaxNumber: | 7065096858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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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 | 363L00000X | RN107717 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 161722931A | 05 | GA | MEDICAID |