Basic Information
| Provider Information | |||||||||
| NPI: | 1477633709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRADDOCK | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 714960 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432714960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053221808 | ||||||||
| FaxNumber: | 2053221851 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053221808 | ||||||||
| FaxNumber: | 2053221851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 367500000X | 23841 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1067620 | 01 | WV | WORKERS' COMP | OTHER | 74425802 | 05 | KY | MEDICAID | 0068016000 | 05 | WV | MEDICAID | P00227786 | 01 | PALMETTO GBA-RR MEDICARE | OTHER | 0868824 | 05 | OH | MEDICAID |