Healthcare Provider Details

I. General information

NPI: 1790447175
Provider Name (Legal Business Name): KRISTIE LEE BRACKETT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 SAINT MARYS DR
EVANSVILLE IN
47714-0508
US

IV. Provider business mailing address

711 SAINT MARYS DR
EVANSVILLE IN
47714-0508
US

V. Phone/Fax

Practice location:
  • Phone: 812-476-4362
  • Fax: 812-469-3700
Mailing address:
  • Phone: 812-476-4362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71011639A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71011639A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: