Provider Demographics
NPI:1194135566
Name:BRAGG, BRANDI NICOLE
Entity type:Individual
Prefix:MS
First Name:BRANDI
Middle Name:NICOLE
Last Name:BRAGG
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 1:531 PAR DR APT 9
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1666
Mailing Address - Country:US
Mailing Address - Phone:901-335-5091
Mailing Address - Fax:
Practice Address - Street 1:531 PAR DR APT 9
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1666
Practice Address - Country:US
Practice Address - Phone:901-335-5091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator