Healthcare Provider Details

I. General information

NPI: 1649195645
Provider Name (Legal Business Name): JUSTICE M BRACKNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 DR MARY MCLEOD BETHUNE BLVD
DAYTONA BEACH FL
32114-3012
US

IV. Provider business mailing address

1400 S NOVA RD APT 176
DAYTONA BEACH FL
32114-7328
US

V. Phone/Fax

Practice location:
  • Phone: 386-481-2215
  • Fax: 386-481-2238
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL7613
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: