=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295019503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIANN M CRADDOCK NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2011
-----------------------------------------------------
Last Update Date | 09/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12881 N IH 35
-----------------------------------------------------
City | LIVE OAK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78233-2966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-742-6555
-----------------------------------------------------
Fax | 732-587-5486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2961 MOSSROCK
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78230-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-731-4800
-----------------------------------------------------
Fax | 210-731-4810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 661440
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP120818
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------