MEDICARE: ANGIE CRADDIETH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency
2	3747P1801X	Personal Care Attendant		MS

General Provider Information

NPI Number	:	1063138931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGIE CRADDIETH

Provider Business Mailing Address
First Line	:	2240 MILITARY RD STE 3
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2456
Country	:	US
Telephone Number	:	662-798-0757
Fax Number	:	662-570-1450

Provider Business Practice Location Address
First Line	:	2240 MILITARY RD STE 3
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2456
Country	:	US
Telephone Number	:	662-364-1058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2022
Last Update Date	:	11/13/2024

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Directions to “ ANGIE CRADDIETH ” Practice Location

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