1336490713 NPI number — LACIE A BRACKEEN CFNP

Table of content: LACIE A BRACKEEN CFNP (NPI 1336490713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336490713 NPI number — LACIE A BRACKEEN CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRACKEEN
Provider First Name:
LACIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ARRINGTON
Provider Other First Name:
LACIE
Provider Other Middle Name:
F
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CFNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336490713
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 BAKER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38756-3401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-686-4121
Provider Business Mailing Address Fax Number:
662-686-4770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 BAKER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38756-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-686-4121
Provider Business Practice Location Address Fax Number:
662-686-4770
Provider Enumeration Date:
09/26/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R858018 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 06425036 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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