Healthcare Provider Details

I. General information

NPI: 1336782747
Provider Name (Legal Business Name): KERRI LYNN CRADDOCK APRN, CNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4846 LARIMER PKWY
JOHNSTOWN CO
80534-9012
US

IV. Provider business mailing address

4846 LARIMER PKWY
JOHNSTOWN CO
80534-9012
US

V. Phone/Fax

Practice location:
  • Phone: 970-624-2834
  • Fax: 970-624-2835
Mailing address:
  • Phone: 970-624-2834
  • Fax: 970-624-2835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1674643
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN.0996569-NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58099
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.0996569-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: