Healthcare Provider Details

I. General information

NPI: 1386119188
Provider Name (Legal Business Name): CALEB THOMAS BRACKIN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N LA BREA AVE
LOS ANGELES CA
90028-7504
US

IV. Provider business mailing address

1300 N LA BREA AVE
LOS ANGELES CA
90028-7504
US

V. Phone/Fax

Practice location:
  • Phone: 323-464-1336
  • Fax: 323-464-2163
Mailing address:
  • Phone: 323-464-1336
  • Fax: 323-464-2163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number24889
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95019522
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF345890
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: