Provider Demographics
NPI:1366163883
Name:CRAFTER, JANIQUE SHONTIA
Entity type:Individual
Prefix:MS
First Name:JANIQUE
Middle Name:SHONTIA
Last Name:CRAFTER
Suffix:
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 1:3926 LINDSEY DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-3941
Mailing Address - Country:US
Mailing Address - Phone:678-608-6131
Mailing Address - Fax:
Practice Address - Street 1:3926 LINDSEY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3941
Practice Address - Country:US
Practice Address - Phone:678-608-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052358346172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver