=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336782747
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRI LYNN CRADDOCK APRN, CNP, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2019
-----------------------------------------------------
Last Update Date | 07/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4846 LARIMER PKWY
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80534-9012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-624-2834
-----------------------------------------------------
Fax | 970-624-2835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4846 LARIMER PKWY
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80534-9012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-624-2834
-----------------------------------------------------
Fax | 970-624-2835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN.1674643
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APN.0996569-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 58099
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APN.0996569-NP
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------