MEDICARE: PHYLLIS ELAINE BRAGG NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71003158B	IN

General Provider Information

NPI Number	:	1861724833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS ELAINE BRAGG NP

Provider Business Mailing Address
First Line	:	3103 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4738
Country	:	US
Telephone Number	:	260-373-9330
Fax Number	:

Provider Business Practice Location Address
First Line	:	5546 THORNBRIAR LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-3890
Country	:	US
Telephone Number	:	260-750-2074
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2010
Last Update Date	:	02/02/2010

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