MEDICARE: AMANDA FISHER CRADDOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	F406770-01	NY
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	29243	SC

General Provider Information

NPI Number	:	1275356206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA FISHER CRADDOCK

Provider Business Mailing Address
First Line	:	199 SCHENCK AVE PH 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-4580
Country	:	US
Telephone Number	:	864-367-3161
Fax Number	:

Provider Business Practice Location Address
First Line	:	199 SCHENCK AVE PH 6
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11207-4580
Country	:	US
Telephone Number	:	864-367-3161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2024
Last Update Date	:	05/05/2026

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Directions to “ AMANDA FISHER CRADDOCK ” Practice Location

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