Healthcare Provider Details

I. General information

NPI: 1376210609
Provider Name (Legal Business Name): TAMMY CRACKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 E HOME RD
SPRINGFIELD OH
45503-2520
US

IV. Provider business mailing address

2317 E HOME RD
SPRINGFIELD OH
45503-2520
US

V. Phone/Fax

Practice location:
  • Phone: 937-390-8060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN.443276
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: