Basic Information
| Provider Information | |||||||||
| NPI: | 1639684657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCRACKEN | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | ASHLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 357 | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299362605 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 776 2ND ST E | ||||||||
| Address2: | |||||||||
| City: | ESTILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299184926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8036252548 | ||||||||
| FaxNumber: | 8036252801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2017 | ||||||||
| LastUpdateDate: | 12/13/2017 | ||||||||
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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 | 363LF0000X | 21497 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 21497 | 01 | SC | STATE LICENSE | OTHER |