Provider Demographics
NPI:1417033317
Name:CRADDOCK, MARY AGNES (ARNP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:AGNES
Last Name:CRADDOCK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:653 WILLOW GROVE ST STE 2000
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-1789
Practice Address - Country:US
Practice Address - Phone:908-441-7201
Practice Address - Fax:908-441-1292
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14889300363LF0000X
FLARNP3243012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307999600Medicaid
AD434ZMedicare PIN