Provider Demographics
NPI:1871712570
Name:CRADDOCK, GWEN I
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:CRADDOCK
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5942 WILSON DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2637
Mailing Address - Country:US
Mailing Address - Phone:304-733-6497
Mailing Address - Fax:304-733-6498
Practice Address - Street 1:5942 WILSON DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2637
Practice Address - Country:US
Practice Address - Phone:304-733-6497
Practice Address - Fax:304-733-6498
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist