Provider Demographics
NPI:1427429356
Name:BRAGG, LYNNETTE WELLS (RN, CCM)
Entity type:Individual
Prefix:
First Name:LYNNETTE
Middle Name:WELLS
Last Name:BRAGG
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:LORA
Other - Middle Name:LYNNETTE
Other - Last Name:BRAGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, CCM
Mailing Address - Street 1:1115 KENTUCKY LN
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-9368
Mailing Address - Country:US
Mailing Address - Phone:912-398-8234
Mailing Address - Fax:866-259-4181
Practice Address - Street 1:1115 KENTUCKY LN
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-9368
Practice Address - Country:US
Practice Address - Phone:912-398-8234
Practice Address - Fax:866-259-4181
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1145809163W00000X
GARN035687163W00000X
NJ20888171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163W00000XNursing Service ProvidersRegistered Nurse