Healthcare Provider Details

I. General information

NPI: 1679895296
Provider Name (Legal Business Name): ALISA ROCHELLE CRADDOCK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 N US HIGHWAY 421
CLINTON NC
28328-0410
US

IV. Provider business mailing address

PO BOX 187
FAISON NC
28341-0187
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-1462
  • Fax: 910-808-1040
Mailing address:
  • Phone: 910-267-2042
  • Fax: 855-996-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number178364
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF02241056
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: