Provider Demographics
NPI:1932176328
Name:BRAESE, NANCY ELLEN (DO)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ELLEN
Last Name:BRAESE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-2526
Mailing Address - Country:US
Mailing Address - Phone:603-740-4478
Mailing Address - Fax:
Practice Address - Street 1:10 MEMBERS WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-5933
Practice Address - Country:US
Practice Address - Phone:603-609-6930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7457207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3076887Medicaid
B97942Medicare UPIN
NH3076887Medicaid