=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407290596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACKIE LYNNE CRAFT ANP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2013
-----------------------------------------------------
Last Update Date | 04/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 373 CECIL D QUILLEN DR STE 101 373 CECIL D. QUILLEN DRIVE SUITE 101
-----------------------------------------------------
City | DUFFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24244-4085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-431-1638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 373 CECIL D QUILLEN DR STE 101 REGIONAL HEALTH RESOURCES
-----------------------------------------------------
City | DUFFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24244-4085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-431-1638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 0024170808
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------