Provider Demographics
NPI:1861724833
Name:BRAGG, PHYLLIS ELAINE (NP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ELAINE
Last Name:BRAGG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4738
Mailing Address - Country:US
Mailing Address - Phone:260-373-9330
Mailing Address - Fax:
Practice Address - Street 1:5546 THORNBRIAR LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3890
Practice Address - Country:US
Practice Address - Phone:260-750-2074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003158B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily